Provider Demographics
NPI:1619255635
Name:GENSTERBLUM, ANTHONY EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:EDWARD
Last Name:GENSTERBLUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1012
Mailing Address - Country:US
Mailing Address - Phone:517-783-4418
Mailing Address - Fax:517-783-4504
Practice Address - Street 1:505 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1012
Practice Address - Country:US
Practice Address - Phone:517-783-4418
Practice Address - Fax:517-783-4504
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011915103TC0700X
MI68010600631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical