Provider Demographics
NPI:1194966192
Name:KORZENOWSKI, GREG BERNARD (PHD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:BERNARD
Last Name:KORZENOWSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 55TH ST
Mailing Address - Street 2:
Mailing Address - City:FENNVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49408-9402
Mailing Address - Country:US
Mailing Address - Phone:269-561-5096
Mailing Address - Fax:269-561-8267
Practice Address - Street 1:2429 55TH ST
Practice Address - Street 2:
Practice Address - City:FENNVILLE
Practice Address - State:MI
Practice Address - Zip Code:49408-9402
Practice Address - Country:US
Practice Address - Phone:269-561-5096
Practice Address - Fax:269-561-8267
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009786103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM20980Medicare PIN