Healthcare Provider Details

I. General information

NPI: 1578832168
Provider Name (Legal Business Name): MARCIE M DULLEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date: 03/05/2019
Reactivation Date: 03/27/2019

III. Provider practice location address

800 MONROE AVE NW STE 202
GRAND RAPIDS MI
49503-1448
US

IV. Provider business mailing address

6973 BREWER AVE NE
ROCKFORD MI
49341-9213
US

V. Phone/Fax

Practice location:
  • Phone: 586-215-3435
  • Fax:
Mailing address:
  • Phone: 586-215-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012719
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: