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General NPI Number Information
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NPI Number | 1760799183
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Entity Type | Individual
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Provider Name | MARY DIANE JUNGLAS PH.D, LMSW, CAAC
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Gender | Female
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Dates
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Enumeration Date | 09/07/2010
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Last Update Date | 09/07/2010
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Provider Practice Location Address
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Address Line | 15000 GRATIOT AVE
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City | DETROIT
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State | MI
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Zip | 48205-1973
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Country | US
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Telephone | 313-245-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 51108 SHELBY RD
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City | SHELBY TOWNSHIP
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State | MI
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Zip | 48316-4051
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Country | US
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Telephone | 586-254-1676
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | C-02432
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801057791
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License Number State | MI
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