Provider Demographics
NPI:1144598616
Name:HILGENDORF, GINA ROSE
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:ROSE
Last Name:HILGENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22550 HALL RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1189
Mailing Address - Country:US
Mailing Address - Phone:586-948-6162
Mailing Address - Fax:586-469-7674
Practice Address - Street 1:22550 HALL RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1189
Practice Address - Country:US
Practice Address - Phone:586-948-6162
Practice Address - Fax:586-469-7674
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012131103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist