Healthcare Provider Details

I. General information

NPI: 1316662703
Provider Name (Legal Business Name): FREDERICK JOSEPH DELONG IV MA, LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 RIDGES BND APT 201
GRAND RAPIDS MI
49546-5437
US

IV. Provider business mailing address

3120 RIDGES BND APT 201
GRAND RAPIDS MI
49546-5437
US

V. Phone/Fax

Practice location:
  • Phone: 612-770-8223
  • Fax:
Mailing address:
  • Phone: 612-770-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451022421
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: