=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831348143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT TERRY EKKENS MALMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2008
-----------------------------------------------------
Last Update Date | 09/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1049 E NEWELL ST
-----------------------------------------------------
City | WHITE CLOUD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49349-8795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-689-7330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1505 SANDY POINT AVE SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-9725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-676-2713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401001743
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801034253
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------