Provider Demographics
NPI:1669586277
Name:CLEMENS-GRAY, MICHELLE ROSE (MSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:CLEMENS-GRAY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2317
Mailing Address - Country:US
Mailing Address - Phone:231-935-0574
Mailing Address - Fax:231-935-0387
Practice Address - Street 1:1213 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2317
Practice Address - Country:US
Practice Address - Phone:231-935-0574
Practice Address - Fax:231-935-0387
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010702751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P70264Medicare UPIN
MI0P09280Medicare PIN