Healthcare Provider Details

I. General information

NPI: 1609803469
Provider Name (Legal Business Name): PAUL CRITELLI PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 IROQUOIS DR SE
GRAND RAPIDS MI
49506-3373
US

IV. Provider business mailing address

858 IROQUOIS DR SE
GRAND RAPIDS MI
49506-3373
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-4738
  • Fax: 616-248-4745
Mailing address:
  • Phone: 616-248-4738
  • Fax: 616-248-4745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301002801
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: