=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104108836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPLOYEE ASSISTANCE CENTER FULTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2011
-----------------------------------------------------
Last Update Date | 09/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 FULTON
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-227-0905
-----------------------------------------------------
Fax | 616-975-3565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 CHERRY
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-965-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHRIS SHEA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-776-2129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------