Healthcare Provider Details

I. General information

NPI: 1336711480
Provider Name (Legal Business Name): ISRAEL URIAS LEE OSTRANDER D-TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 OLD 28TH ST SE STE 4
GRAND RAPIDS MI
49546-6932
US

IV. Provider business mailing address

940 WISCONSIN AVE # 1
SAINT JOSEPH MI
49085-1538
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-5414
  • Fax:
Mailing address:
  • Phone: 231-408-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6352001140
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: