Provider Demographics
NPI:1285858076
Name:GROGAN, MARY J (ACSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:GROGAN
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18187 N TERRITORIAL RD APT A
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-9154
Mailing Address - Country:US
Mailing Address - Phone:517-936-7277
Mailing Address - Fax:734-433-4213
Practice Address - Street 1:612 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1907
Practice Address - Country:US
Practice Address - Phone:517-936-7277
Practice Address - Fax:734-433-4213
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010600971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP20120Medicare ID - Type Unspecified