Healthcare Provider Details

I. General information

NPI: 1689132003
Provider Name (Legal Business Name): VICTORIA IVY GRATTAN LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 RUSSELL ST
DETROIT MI
48207-4825
US

IV. Provider business mailing address

2925 RUSSELL ST
DETROIT MI
48207-4825
US

V. Phone/Fax

Practice location:
  • Phone: 313-396-5300
  • Fax: 313-396-5353
Mailing address:
  • Phone: 313-396-5300
  • Fax: 313-396-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401016977
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: