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General NPI Number Information
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NPI Number | 1265660963
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Entity Type | Individual
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Provider Name | GARY MICHAEL COLE LLP
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Gender | Male
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Dates
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Enumeration Date | 07/01/2009
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Last Update Date | 07/01/2009
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Provider Practice Location Address
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Address Line | 1115 BALL AVE NE BLDG C
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-5904
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Country | US
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Telephone | 616-632-7744
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Fax | 616-632-7744
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Provider Business Mailing Address
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Address Line | 1075 WALL LAKE DR
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City | DELTON
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State | MI
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Zip | 49046-9517
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Country | US
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Telephone | 269-623-5771
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Fax | 269-623-5771
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 6301008599
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License Number State | MI
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