Provider Demographics
NPI:1629073408
Name:FAIRGRIEVE, MARY COLLINS (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLINS
Last Name:FAIRGRIEVE
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:ONEKAMA
Mailing Address - State:MI
Mailing Address - Zip Code:49675-0127
Mailing Address - Country:US
Mailing Address - Phone:231-887-7363
Mailing Address - Fax:
Practice Address - Street 1:50 FILER ST
Practice Address - Street 2:SUITE 210H
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2726
Practice Address - Country:US
Practice Address - Phone:231-887-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010192961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2530OtherMEDICARE PTAN
6221012OtherUNITED BEHAVIORAL HEALTH
MI037172OtherVALUE OPTIONS
MI138355OtherMAGELLAN BEHAVIORAL HEALTH
MI0899098OtherBLUE CROSS BLUE SHIELD MI