Healthcare Provider Details

I. General information

NPI: 1184996969
Provider Name (Legal Business Name): JOSEPH EDWARD BUDNICK LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 BROWNWOOD AVE NW
GRAND RAPIDS MI
49504-3653
US

IV. Provider business mailing address

1150 BROWNWOOD AVE NW
GRAND RAPIDS MI
49504-3653
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-0367
  • Fax:
Mailing address:
  • Phone: 616-453-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301011104
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: