Healthcare Provider Details

I. General information

NPI: 1487392809
Provider Name (Legal Business Name): JAMES EUGENE LOS PHD, LP, NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

5242 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1084
US

V. Phone/Fax

Practice location:
  • Phone: 616-393-2200
  • Fax:
Mailing address:
  • Phone: 616-393-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6301019062
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: