Healthcare Provider Details

I. General information

NPI: 1871010009
Provider Name (Legal Business Name): MR. DURIEL ULYSSES COHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E BELTLINE AVE SE STE 250
GRAND RAPIDS MI
49506-4360
US

IV. Provider business mailing address

1418 COLORADO AVE SE
GRAND RAPIDS MI
49507-2213
US

V. Phone/Fax

Practice location:
  • Phone: 616-414-0019
  • Fax:
Mailing address:
  • Phone: 616-414-0019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401222766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: