Healthcare Provider Details

I. General information

NPI: 1770730434
Provider Name (Legal Business Name): KURT THOMAS ELLIS LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 PLAINFIELD AVE NE SUITE C
GRAND RAPIDS MI
49525-1010
US

IV. Provider business mailing address

4829 E BELTLINE AVE NE STE 103
GRAND RAPIDS MI
49525-9349
US

V. Phone/Fax

Practice location:
  • Phone: 616-217-8612
  • Fax:
Mailing address:
  • Phone: 616-217-8612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301008881
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6301008881
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: