Basic Information
| Provider Information | |||||||||
| NPI: | 1104108836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMPLOYEE ASSISTANCE CENTER FULTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHERRY | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 321 FULTON | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002270905 | ||||||||
| FaxNumber: | 6169753565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHEA | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6167762129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHERRY STREET HEALTH SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.