Healthcare Provider Details

I. General information

NPI: 1437452406
Provider Name (Legal Business Name): EVAN DANIEL PARKS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 01/28/2023
Certification Date: 01/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4656
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8402
  • Fax: 616-840-9771
Mailing address:
  • Phone: 616-840-8000
  • Fax: 616-840-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301006916
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: