Basic Information
| Provider Information | |||||||||
| NPI: | 1447525712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSS | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | COURTNEY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865013070 | ||||||||
| FaxNumber: | 2489200550 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865013070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 6801099613 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.