Provider Demographics
NPI:1962697235
Name:GROSMARK, CAROL ELAINE (LMSW, CAAC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELAINE
Last Name:GROSMARK
Suffix:
Gender:F
Credentials:LMSW, CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 LAKE AVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3283
Mailing Address - Country:US
Mailing Address - Phone:231-883-5291
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010885111041C0700X
MIC-01307101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)