Healthcare Provider Details

I. General information

NPI: 1821451295
Provider Name (Legal Business Name): GREGORY BEDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26300 OUTER DR
LINCOLN PARK MI
48146-2019
US

IV. Provider business mailing address

1267 MAPLE AVE
MONROE MI
48162-3004
US

V. Phone/Fax

Practice location:
  • Phone: 313-388-4630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401017030
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401013114
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401017030
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: