Provider Demographics
NPI:1578832168
Name:DULLEA, MARCIE M
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:M
Last Name:DULLEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6973 BREWER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9213
Mailing Address - Country:US
Mailing Address - Phone:586-215-3435
Mailing Address - Fax:
Practice Address - Street 1:800 MONROE AVE NW STE 202
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1448
Practice Address - Country:US
Practice Address - Phone:586-215-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2022-01-05
Deactivation Date:2019-03-05
Deactivation Code:
Reactivation Date:2019-03-27
Provider Licenses
StateLicense IDTaxonomies
MI6401012719101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional