Provider Demographics
NPI:1598907818
Name:DUGAN, LARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:DUGAN
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 1:3934 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2148
Mailing Address - Country:US
Mailing Address - Phone:616-954-0557
Mailing Address - Fax:616-954-2878
Practice Address - Street 1:3934 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2148
Practice Address - Country:US
Practice Address - Phone:616-954-0557
Practice Address - Fax:616-954-2878
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301 001929103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD 145 44 7 622OtherBC/BS 620D145440