Healthcare Provider Details

I. General information

NPI: 1336282722
Provider Name (Legal Business Name): HARLEY DEAN DORMAN II ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 EAST PARIS AVE SE SUITE 203
GRAND RAPIDS MI
49546-2426
US

IV. Provider business mailing address

2305 EAST PARIS AVE. SUITE 203
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-929-0226
  • Fax:
Mailing address:
  • Phone: 616-929-0226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number8795
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: