Healthcare Provider Details

I. General information

NPI: 1790802833
Provider Name (Legal Business Name): MARK ALAN SANFORD-PELCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

1349 BUTH DR NE
COMSTOCK PARK MI
49321-9698
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7207
  • Fax: 616-259-7261
Mailing address:
  • Phone: 616-581-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401007748
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301007605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: