Basic Information
| Provider Information | |||||||||
| NPI: | 1477610020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREBE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475034 | ||||||||
| FaxNumber: | 2313475194 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475034 | ||||||||
| FaxNumber: | 2313475194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301007160 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 680B410940 | 01 | MI | BLUE CROSS | OTHER |