Provider Demographics
NPI:1760799183
Name:JUNGLAS, MARY DIANE (PHD, LMSW, CAAC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:DIANE
Last Name:JUNGLAS
Suffix:
Gender:F
Credentials:PHD, LMSW, CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51108 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-4051
Mailing Address - Country:US
Mailing Address - Phone:586-254-1676
Mailing Address - Fax:
Practice Address - Street 1:15000 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1973
Practice Address - Country:US
Practice Address - Phone:313-245-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02432101YA0400X
MI68010577911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)