Healthcare Provider Details

I. General information

NPI: 1184789737
Provider Name (Legal Business Name): JOSEPH L GAGE LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

736 UNION AVE NE
GRAND RAPIDS MI
49503-1732
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-8789
  • Fax: 616-475-7570
Mailing address:
  • Phone: 616-742-0185
  • Fax: 616-897-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703077967
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6031014166
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: