Provider Demographics
NPI:1700825734
Name:GROSSBERG, INGRID NORENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:NORENE
Last Name:GROSSBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33045 HAMILTON CT
Mailing Address - Street 2:SUITE W-300
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3385
Mailing Address - Country:US
Mailing Address - Phone:248-848-1558
Mailing Address - Fax:248-848-3592
Practice Address - Street 1:33045 HAMILTON CT
Practice Address - Street 2:SUITE W-300
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3385
Practice Address - Country:US
Practice Address - Phone:248-848-1558
Practice Address - Fax:248-848-3592
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0001011041C0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP12140001Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER