1679899280 NPI number — GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC

Table of content: (NPI 1679899280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679899280 NPI number — GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC
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:
6
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:
1679899280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4519 CASCADE RD SE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-949-6262
Provider Business Mailing Address Fax Number:
616-425-2003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4519 CASCADE RD SE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-3666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-949-6262
Provider Business Practice Location Address Fax Number:
616-425-2003
Provider Enumeration Date:
04/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CARINO
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
616-949-6262

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  680103034469 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6801034469 . This is a "STATE OF MICHIGAN DEPARTMENT OF COMMUNITY HEALTH LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 881817049 . This is a "NATIONAL ASSOCIATION OF SOCIAL WORKERS ACADEMY OF CERTIFIED SOCIAL WORKERS" identifier . This identifiers is of the category "OTHER".




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