Provider Demographics
NPI:1275661951
Name:MACISAK, GREGORY M
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:M
Last Name:MACISAK
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 1:2082 MALVINA ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3458
Mailing Address - Country:US
Mailing Address - Phone:313-381-1681
Mailing Address - Fax:
Practice Address - Street 1:25401 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2240
Practice Address - Country:US
Practice Address - Phone:586-466-6912
Practice Address - Fax:586-466-6961
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker