Provider Demographics
NPI:1194193953
Name:BOOKER, MARILYN (MA, LSC, LLPC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BOOKER
Suffix:
Gender:F
Credentials:MA, LSC, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 PLAINFIELD AVE NE STE 5
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1010
Mailing Address - Country:US
Mailing Address - Phone:616-460-6448
Mailing Address - Fax:
Practice Address - Street 1:4920 PLAINFIELD AVE NE STE 5
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1010
Practice Address - Country:US
Practice Address - Phone:616-460-6448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640101436101YP2500X
MISC0000000793839101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool