Provider Demographics
NPI:1659903490
Name:BILDERBACK, JEREMY RYAN (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RYAN
Last Name:BILDERBACK
Suffix:
Gender:M
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-9317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 S GARFIELD AVE STE 3A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2403
Practice Address - Country:US
Practice Address - Phone:231-392-4638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6401017749101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor