Provider Demographics
NPI:1851392310
Name:GROSENBACH, MILTON JAMES JR (EDD PC)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:JAMES
Last Name:GROSENBACH
Suffix:JR
Gender:M
Credentials:EDD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3562 S LAPEER RD STE F
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-8998
Mailing Address - Country:US
Mailing Address - Phone:810-678-8898
Mailing Address - Fax:810-668-8808
Practice Address - Street 1:3562 S LAPEER RD STE F
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-8998
Practice Address - Country:US
Practice Address - Phone:810-678-8898
Practice Address - Fax:810-668-8808
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003782103T00000X
MI4101005216106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M43200OtherMEDICARE
MI620G44601OtherHEALTHPLUS
MIOM43200OtherMEDICARE
MI680D44501OtherBLUECROSS/BLUESHIELD
MIOM43200OtherMEDICARE
MIR67377Medicare UPIN