Provider Demographics
NPI:1407022874
Name:FIELDS, ANDRE RUBIN (TLLP)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:RUBIN
Last Name:FIELDS
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 ROSEWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3931
Mailing Address - Country:US
Mailing Address - Phone:616-734-9779
Mailing Address - Fax:
Practice Address - Street 1:8175 CREEKSIDE DR
Practice Address - Street 2:SUITE 264
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5377
Practice Address - Country:US
Practice Address - Phone:269-321-5033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013802103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling