Healthcare Provider Details

I. General information

NPI: 1114447745
Provider Name (Legal Business Name): ANDREA GUMBKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 MICHIGAN ST NE
GRAND RAPIDS MI
49525-3408
US

IV. Provider business mailing address

3403 MICHIGAN ST NE
GRAND RAPIDS MI
49525-3408
US

V. Phone/Fax

Practice location:
  • Phone: 616-350-8924
  • Fax:
Mailing address:
  • Phone: 616-350-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number630100935
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: