Provider Demographics
NPI:1619063898
Name:FOGEL, DAN SIEGEL (LMSW)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:SIEGEL
Last Name:FOGEL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 SHELDON BLVD SE
Practice Address - Street 2:SUITE 100 & 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4224
Practice Address - Country:US
Practice Address - Phone:616-391-2420
Practice Address - Fax:616-391-4425
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801057400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16262033Medicare UPIN