Provider Demographics
NPI:1518030949
Name:ENSROTH, MARY V (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:ENSROTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20300 CIVIC CENTER DR
Mailing Address - Street 2:STE 303
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4169
Mailing Address - Country:US
Mailing Address - Phone:248-559-8190
Mailing Address - Fax:248-559-8776
Practice Address - Street 1:20300 CIVIC CENTER DR
Practice Address - Street 2:STE 303
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4169
Practice Address - Country:US
Practice Address - Phone:248-559-8190
Practice Address - Fax:248-559-8776
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801008924104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
N90420003Medicare ID - Type Unspecified