Healthcare Provider Details

I. General information

NPI: 1831348143
Provider Name (Legal Business Name): ROBERT TERRY EKKENS MALMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 E NEWELL ST
WHITE CLOUD MI
49349-8795
US

IV. Provider business mailing address

1505 SANDY POINT AVE SE
GRAND RAPIDS MI
49546-9725
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7330
  • Fax:
Mailing address:
  • Phone: 616-676-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401001743
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801034253
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: