Provider Demographics
NPI:1275079105
Name:PRUSAKIEWICZ, GREG ALLEN (BS)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:ALLEN
Last Name:PRUSAKIEWICZ
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 GARFIELD WOODS DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-5160
Mailing Address - Country:US
Mailing Address - Phone:231-668-4909
Mailing Address - Fax:
Practice Address - Street 1:990 GARFIELD WOODS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-5160
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician