1457915647 NPI number — RISE: COUNSELING GROUP AND HOLISTIC WELLNESS CENTER LLC

Table of content: (NPI 1457915647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457915647 NPI number — RISE: COUNSELING GROUP AND HOLISTIC WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RISE: COUNSELING GROUP AND HOLISTIC WELLNESS CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457915647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
59207 RAVENNA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTAWAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49071-9620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 W CENTRE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-5332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-796-5831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOCK
Authorized Official First Name:
ELISABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER/CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
269-352-2281

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)