Provider Demographics
NPI:1942890918
Name:GRZEGORCZYK, ETHAN PATRICK-JAMES
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:PATRICK-JAMES
Last Name:GRZEGORCZYK
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:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:734-203-0181
Mailing Address - Fax:
Practice Address - Street 1:1625 CONCENTRIC BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9542
Practice Address - Country:US
Practice Address - Phone:989-341-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2023-09-06
Deactivation Date:2021-01-22
Deactivation Code:
Reactivation Date:2021-03-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician