Provider Demographics
NPI:1952611782
Name:DEBRA MARY GREGORY PC LLC
Entity Type:Organization
Organization Name:DEBRA MARY GREGORY PC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:248-568-1344
Mailing Address - Street 1:5639 SASHABAW RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3149
Mailing Address - Country:US
Mailing Address - Phone:248-568-1344
Mailing Address - Fax:248-922-9040
Practice Address - Street 1:7130 WALNUT LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323
Practice Address - Country:US
Practice Address - Phone:248-568-1344
Practice Address - Fax:248-922-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010337611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008965160OtherBLUE CROSS BLUE SHIELD
MIP12210001Medicare PIN