Provider Demographics
NPI:1568500437
Name:WASILOWSKI, GREGORY ANTHONY
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ANTHONY
Last Name:WASILOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43567 NEBEL TRL
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-2468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21885 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1030
Practice Address - Country:US
Practice Address - Phone:586-469-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801064199104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker