Provider Demographics
NPI:1497536528
Name:MULDER, BRIAN JAMES (LPC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:MULDER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 COLORADO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2214
Mailing Address - Country:US
Mailing Address - Phone:616-610-0286
Mailing Address - Fax:
Practice Address - Street 1:30 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-303-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional