Provider Demographics
NPI:1245445345
Name:HAMBERG, PHILLIP DEAN (LMFT LMSW LICENSED M)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DEAN
Last Name:HAMBERG
Suffix:
Gender:M
Credentials:LMFT LMSW LICENSED M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EAST PARIS SE
Mailing Address - Street 2:EAST PARIS MEDICAL BUILDING SUITE 140
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-957-2416
Mailing Address - Fax:616-669-1717
Practice Address - Street 1:1000 EAST PARIS SE
Practice Address - Street 2:EAST PARIS MEDICAL BUILDING SUITE 140
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-957-2416
Practice Address - Fax:616-669-1717
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801014344104100000X
MI4101005552106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist