Healthcare Provider Details

I. General information

NPI: 1013520550
Provider Name (Legal Business Name): MARY MOONEY GRETTENBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8811 VERNIER RD STE A
IRA MI
48023-2909
US

IV. Provider business mailing address

PO BOX 230244
FAIR HAVEN MI
48023-0244
US

V. Phone/Fax

Practice location:
  • Phone: 586-307-4659
  • Fax: 586-500-9584
Mailing address:
  • Phone: 586-307-4659
  • Fax: 586-500-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115354
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: