Healthcare Provider Details

I. General information

NPI: 1730631581
Provider Name (Legal Business Name): GARY ATKINS JR. TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

IV. Provider business mailing address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-4777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301016895
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: