Healthcare Provider Details

I. General information

NPI: 1801456819
Provider Name (Legal Business Name): KENNETH MICHAEL PIERSON PSY. S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BOWNE ST NE
GRAND RAPIDS MI
49505-4014
US

IV. Provider business mailing address

100 BOWNE ST NE
GRAND RAPIDS MI
49505-4014
US

V. Phone/Fax

Practice location:
  • Phone: 810-348-4246
  • Fax:
Mailing address:
  • Phone: 810-348-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP0000000950458
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: