Healthcare Provider Details

I. General information

NPI: 1932348588
Provider Name (Legal Business Name): DANIEL LEE LOOSENORT REV. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 NEW HOLLAND ST
HUDSONVILLE MI
49426-8804
US

IV. Provider business mailing address

10846 LONG POINT DR
PLAINWELL MI
49080-9204
US

V. Phone/Fax

Practice location:
  • Phone: 269-779-1186
  • Fax:
Mailing address:
  • Phone: 269-779-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: