=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356985386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW M SCHMUKER LLPC, LLMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2019
-----------------------------------------------------
Last Update Date | 11/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4565 WILSON AVE SW STE 3A
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-805-4416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3109 72ND ST SW
-----------------------------------------------------
City | BYRON CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49315-8009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-528-0352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4101006783
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401016470
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------