Provider Demographics
NPI:1538287495
Name:DE BOE, JAMES BERNARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BERNARD
Last Name:DE BOE
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 1:4131 EMBASSY DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2418
Mailing Address - Country:US
Mailing Address - Phone:616-975-0700
Mailing Address - Fax:616-975-7702
Practice Address - Street 1:4131 EMBASSY DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2418
Practice Address - Country:US
Practice Address - Phone:616-975-0700
Practice Address - Fax:616-975-7702
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006527103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD14673Medicare ID - Type Unspecified