Provider Demographics
NPI:1497382857
Name:KELLY A GROCOFF LLC
Entity Type:Organization
Organization Name:KELLY A GROCOFF LLC
Other - Org Name:CASSELMAN WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-272-5813
Mailing Address - Street 1:122 S MAIN ST STE 360A
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-1932
Mailing Address - Country:US
Mailing Address - Phone:734-926-5366
Mailing Address - Fax:
Practice Address - Street 1:122 S MAIN ST STE 360A
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1932
Practice Address - Country:US
Practice Address - Phone:734-926-5366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-25
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP140669OtherBLUE CROSS BLUE SHIELD OF MICHIGAN