Healthcare Provider Details

I. General information

NPI: 1013549096
Provider Name (Legal Business Name): PATRICK A NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 EASTERN AVE SE
GRAND RAPIDS MI
49507-3632
US

IV. Provider business mailing address

2400 EASTERN AVE SE
GRAND RAPIDS MI
49507-3632
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-3433
  • Fax:
Mailing address:
  • Phone: 616-988-3433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451020840
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451020840
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: