Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 6401000980 | MI |
NPI | 1003250242 |
---|---|
Provider Name | Marilyn Dale |
First Address | Grand Rapids, MI 49525 |
Second Address | Grand Rapids, MI 49525 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2013 |
Last Update Date | 28/04/2020 |