Healthcare Provider Details

I. General information

NPI: 1821133406
Provider Name (Legal Business Name): MARY COMER RUDD-GATES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BROOKTREE LN SE
GRAND RAPIDS MI
49503-3911
US

IV. Provider business mailing address

50 BROOKTREE LN SE
GRAND RAPIDS MI
49503-3911
US

V. Phone/Fax

Practice location:
  • Phone: 860-395-8689
  • Fax:
Mailing address:
  • Phone: 860-395-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001472
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: