MEDICARE: MR. ROGER JAMES GREGORY ICADC, ICCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1861510679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER JAMES GREGORY ICADC, ICCS

Provider Business Mailing Address
First Line	:	9605 WEST GRAND RIVER AVENUE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204
Country	:	US
Telephone Number	:	313-834-5930
Fax Number	:	313-834-4541

Provider Business Practice Location Address
First Line	:	9605 WEST GRAND RIVER
Second Line	:	NARDIN PARK RECOVERY CENTER
City	:	DETROIT
State	:	MI
Zip	:	48204
Country	:	US
Telephone Number	:	313-867-8015
Fax Number	:	313-867-8040

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	06/18/2014

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