Provider Demographics
NPI:1003845314
Name:HAMILTON, MARK THEODORE (LLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THEODORE
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:450 MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9053
Practice Address - Country:US
Practice Address - Phone:616-891-8770
Practice Address - Fax:616-891-3504
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009792103T00000X
MI6361004091103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBC/BSOtherP10D11275