Provider Demographics
NPI:1770253379
Name:GRUGAL, BRYANT
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:GRUGAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:LEROY
Mailing Address - State:MI
Mailing Address - Zip Code:49655-9405
Mailing Address - Country:US
Mailing Address - Phone:231-878-4855
Mailing Address - Fax:
Practice Address - Street 1:500 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9501
Practice Address - Country:US
Practice Address - Phone:231-796-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker