Provider Demographics
NPI:1043982200
Name:GROGITSKY, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GROGITSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11174 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-2702
Mailing Address - Country:US
Mailing Address - Phone:810-991-1114
Mailing Address - Fax:
Practice Address - Street 1:11174 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2702
Practice Address - Country:US
Practice Address - Phone:810-991-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty