Provider Demographics
NPI:1275869109
Name:GERWOLLS, MARILYN KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:KAY
Last Name:GERWOLLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7467 BINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1428
Mailing Address - Country:US
Mailing Address - Phone:313-600-9553
Mailing Address - Fax:
Practice Address - Street 1:7467 BINGHAM ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1428
Practice Address - Country:US
Practice Address - Phone:313-600-9553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008434103T00000X, 103TC0700X, 103TF0200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth