Provider Demographics
NPI:1639656267
Name:CHANDLER, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 PLYMOUTH AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4024
Mailing Address - Country:US
Mailing Address - Phone:616-214-2176
Mailing Address - Fax:
Practice Address - Street 1:1222 PLYMOUTH AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4024
Practice Address - Country:US
Practice Address - Phone:616-214-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC534098549381101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWY0913175107Medicaid