Provider Demographics
NPI:1790802833
Name:SANFORD-PELCHER, MARK ALAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SANFORD-PELCHER
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 1:1349 BUTH DR NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-9698
Mailing Address - Country:US
Mailing Address - Phone:616-581-1214
Mailing Address - Fax:
Practice Address - Street 1:1000 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1455
Practice Address - Country:US
Practice Address - Phone:616-259-7207
Practice Address - Fax:616-259-7261
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007748101YP2500X
MI6301007605103TC1900X
MI6802062714104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker