Provider Demographics
NPI:1780818021
Name:KOLE, MARK A (MA, LLP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:KOLE
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:7895 CURRIER DR STE 100
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4314
Practice Address - Country:US
Practice Address - Phone:269-910-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009502103T00000X
MI6361007089103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist