Provider Demographics
NPI:1821180274
Name:GROH, CARLA J (PHD APRN BC)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:J
Last Name:GROH
Suffix:
Gender:F
Credentials:PHD APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 CONNER
Mailing Address - Street 2:SUITE 2691
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213
Mailing Address - Country:US
Mailing Address - Phone:313-579-1182
Mailing Address - Fax:313-579-5128
Practice Address - Street 1:5555 CONNER
Practice Address - Street 2:SUITE 2691
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:313-579-1182
Practice Address - Fax:313-579-5128
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704098802363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4635769Medicaid
N88860005Medicare ID - Type Unspecified