Provider Demographics
NPI:1285127795
Name:HOEFELMEYER, IAN MIKEL
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MIKEL
Last Name:HOEFELMEYER
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 1:1238 QUARRY AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3132
Mailing Address - Country:US
Mailing Address - Phone:248-622-1595
Mailing Address - Fax:
Practice Address - Street 1:400 RENAISSANCE CTR STE 2600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48243-1502
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-676-9100
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
247200000XOtherPOSITIVE BEHAVIOR SUPPORT CORP.
MI106S00000XMedicaid