Healthcare Provider Details

I. General information

NPI: 1265660963
Provider Name (Legal Business Name): GARY MICHAEL COLE LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE BLDG C
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1075 WALL LAKE DR
DELTON MI
49046-9517
US

V. Phone/Fax

Practice location:
  • Phone: 616-632-7744
  • Fax: 616-632-7744
Mailing address:
  • Phone: 269-623-5771
  • Fax: 269-623-5771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301008599
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: