Provider Demographics
NPI:1568817021
Name:MICHIGAN MENTAL WELLNESS PLLC
Entity Type:Organization
Organization Name:MICHIGAN MENTAL WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-408-3006
Mailing Address - Street 1:37935 W 12 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-6101
Mailing Address - Country:US
Mailing Address - Phone:313-408-3006
Mailing Address - Fax:
Practice Address - Street 1:37935 W 12 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-6101
Practice Address - Country:US
Practice Address - Phone:313-408-3006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53150583442084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty