Provider Demographics
NPI:1063840304
Name:PRINCE, DAVID (LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 TYLER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7350
Mailing Address - Country:US
Mailing Address - Phone:231-342-7890
Mailing Address - Fax:
Practice Address - Street 1:3301 VETERANS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4574
Practice Address - Country:US
Practice Address - Phone:231-342-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional