Healthcare Provider Details

I. General information

NPI: 1285983643
Provider Name (Legal Business Name): GLORIA J WARREN LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY STREET SE SUITE 260
GRAND RAPIDS MI
49506
US

IV. Provider business mailing address

4305 KENTRIDGE SE
GRAND RAPIDS MI
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-3008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401012860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: