Provider Demographics
NPI:1609390335
Name:GROSE, BLAIR NICHOLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:NICHOLE
Last Name:GROSE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5247 WOODLANE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3165
Mailing Address - Country:US
Mailing Address - Phone:586-770-8100
Mailing Address - Fax:
Practice Address - Street 1:320 E BIG BEAVER RD STE 185
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1238
Practice Address - Country:US
Practice Address - Phone:586-292-6347
Practice Address - Fax:248-584-4000
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309632363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health