Healthcare Provider Details

I. General information

NPI: 1497536528
Provider Name (Legal Business Name): BRIAN JAMES MULDER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4304
US

IV. Provider business mailing address

1511 COLORADO AVE SE
GRAND RAPIDS MI
49507-2214
US

V. Phone/Fax

Practice location:
  • Phone: 616-303-1313
  • Fax:
Mailing address:
  • Phone: 616-610-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224160
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: