MEDICARE: DR. LARRY DUGAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301 001929	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OD 145 44 7 622	OTHER	MI	BC/BS 620D145440

General Provider Information

NPI Number	:	1598907818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY DUGAN PH.D.

Provider Business Mailing Address
First Line	:	3934 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2148
Country	:	US
Telephone Number	:	616-954-0557
Fax Number	:	616-954-2878

Provider Business Practice Location Address
First Line	:	3934 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2148
Country	:	US
Telephone Number	:	616-954-0557
Fax Number	:	616-954-2878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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