Healthcare Provider Details

I. General information

NPI: 1053860916
Provider Name (Legal Business Name): RUEBEN LOPEZ LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 E BELTLINE AVE NE STE 4
GRAND RAPIDS MI
49525-9787
US

IV. Provider business mailing address

4867 E BELTLINE AVE NE STE 4
GRAND RAPIDS MI
49525-9787
US

V. Phone/Fax

Practice location:
  • Phone: 616-292-4594
  • Fax:
Mailing address:
  • Phone: 616-292-4594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015211
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: