Healthcare Provider Details

I. General information

NPI: 1821135831
Provider Name (Legal Business Name): MILTON J GROSENBACH EDD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3562 S LAPEER RD SUITE F
METAMORA MI
48455-8998
US

IV. Provider business mailing address

3562 S LAPEER RD SUITE F
METAMORA MI
48455-8998
US

V. Phone/Fax

Practice location:
  • Phone: 810-678-8898
  • Fax: 810-678-8808
Mailing address:
  • Phone: 810-678-8898
  • Fax: 810-678-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301003782
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number4101005216
License Number StateMI

VIII. Authorized Official

Name: DR. MILTON JAMES GROSENBACH JR.
Title or Position: DR OWNER
Credential: EDD PC
Phone: 810-678-8898