Healthcare Provider Details

I. General information

NPI: 1679693329
Provider Name (Legal Business Name): RYANNE LEIGH GRYGORCEWICZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RYANNE LEIGH GOETHE LMSW

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2884 HARWOOD DR
KIMBALL MI
48074-1508
US

IV. Provider business mailing address

2884 HARWOOD DR
KIMBALL MI
48074-1508
US

V. Phone/Fax

Practice location:
  • Phone: 734-755-1117
  • Fax:
Mailing address:
  • Phone: 734-755-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087767
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: