Healthcare Provider Details

I. General information

NPI: 1154827590
Provider Name (Legal Business Name): MATTHEW HAWLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

3720 STANDISH AVE NE
GRAND RAPIDS MI
49525-2222
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax: 616-774-2044
Mailing address:
  • Phone: 616-238-8861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: