Provider Demographics
NPI:1275638041
Name:WILLMARTH, ERIC (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WILLMARTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:STE 305
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0998829OtherHEALTH PLAN OF MI
041493OtherVALUE OPTIONS
MI680D146790OtherBLUE CROSS BLUE SHIELD
041493OtherVALUE OPTIONS