Provider Demographics
NPI:1447397831
Name:IPPEL, THOMAS LEE (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:IPPEL
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 1:2020 RAYBROOK ST SE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7717
Mailing Address - Country:US
Mailing Address - Phone:616-942-9942
Mailing Address - Fax:
Practice Address - Street 1:2020 RAYBROOK ST SE
Practice Address - Street 2:SUITE 203
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7717
Practice Address - Country:US
Practice Address - Phone:616-942-9942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68OD145630OtherBC BS OF MICHIGAN PIN
MION78090Medicare ID - Type Unspecified