Provider Demographics
NPI:1730564055
Name:GIROUX, MARY ROSE (TLLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:GIROUX
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22516 OVERLAKE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3852
Mailing Address - Country:US
Mailing Address - Phone:734-353-3682
Mailing Address - Fax:
Practice Address - Street 1:22516 OVERLAKE ST
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:724-353-3682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical