Provider Demographics
NPI:1447525712
Name:GROSS, COLLEEN COURTNEY
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:COURTNEY
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1168
Mailing Address - Country:US
Mailing Address - Phone:586-501-3070
Mailing Address - Fax:248-920-0550
Practice Address - Street 1:6900 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1168
Practice Address - Country:US
Practice Address - Phone:586-501-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6801099613104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)