Basic Information
| Provider Information | |||||||||
| NPI: | 1457688988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | KATHRYN | ||||||||
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| Credential: | BS, SST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3902 MARK ORR RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480735402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485062673 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 43825 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343973088 | ||||||||
| FaxNumber: | 7343972892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6803086117 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.