Healthcare Provider Details

I. General information

NPI: 1578643169
Provider Name (Legal Business Name): KENNETH M RAPP LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N STATE ST
STANTON MI
48888-9702
US

IV. Provider business mailing address

3435 WATERFORD CT NE
GRAND RAPIDS MI
49525-2641
US

V. Phone/Fax

Practice location:
  • Phone: 989-831-7542
  • Fax: 989-831-7578
Mailing address:
  • Phone: 616-361-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301007891
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: