Healthcare Provider Details

I. General information

NPI: 1215023569
Provider Name (Legal Business Name): MICHAEL DAVID RUCH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 BURTON SE SUITE B
GRAND RAPIDS MI
49546-4398
US

IV. Provider business mailing address

3300 BURTON ST SE STE 106
GRAND RAPIDS MI
49546-4398
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-2576
  • Fax: 616-957-2576
Mailing address:
  • Phone: 616-957-2576
  • Fax: 616-957-2576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301005183
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: