Healthcare Provider Details

I. General information

NPI: 1942488234
Provider Name (Legal Business Name): INTEGRO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE STE 300
JACKSON MI
49202-2179
US

IV. Provider business mailing address

1200 N WEST AVE STE 300
JACKSON MI
49202-2179
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax: 517-784-7040
Mailing address:
  • Phone: 517-789-1234
  • Fax: 517-784-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TRACY ROUMELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 517-789-1234