Provider Demographics
NPI:1114363439
Name:GERECKE, MARTHA E (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:GERECKE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4139 W WALTON BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4187
Mailing Address - Country:US
Mailing Address - Phone:248-599-7590
Mailing Address - Fax:844-270-3954
Practice Address - Street 1:4139 W WALTON BLVD STE D
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4187
Practice Address - Country:US
Practice Address - Phone:248-599-7590
Practice Address - Fax:844-270-3954
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013173101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor