Provider Demographics
NPI:1942426929
Name:MACRAE, DAVID ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROBERT
Last Name:MACRAE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 E BELTLINE AVE SE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7630
Mailing Address - Country:US
Mailing Address - Phone:616-957-3168
Mailing Address - Fax:616-957-4133
Practice Address - Street 1:2025 E BELTLINE AVE SE
Practice Address - Street 2:SUITE #104
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7630
Practice Address - Country:US
Practice Address - Phone:616-957-3168
Practice Address - Fax:616-957-4133
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002310103T00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD14522Medicare ID - Type UnspecifiedPSYCHOLOGIST