Provider Demographics
NPI:1104967405
Name:GOERGEN, MARIANNE (PSYD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:GOERGEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:
Practice Address - Street 1:8435 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1812
Practice Address - Country:US
Practice Address - Phone:810-424-2400
Practice Address - Fax:810-579-7222
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1606356103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1007186OtherMCLAREN HEALTH ADVANTAGE
MI1007251OtherMCLAREN HEALTH PLAN PIN
MI348-776-000OtherMAGELLAN PIN
MI68-0-F3-3300-0OtherBLUE CROSS PIN
MI1007251OtherMCLAREN HEALTH PLAN PIN