1841726809 NPI number — HOPE & WHOLENESS PSYCHOLOGY CENTER, LLC

Table of content: (NPI 1841726809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841726809 NPI number — HOPE & WHOLENESS PSYCHOLOGY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOPE & WHOLENESS PSYCHOLOGY 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:
1841726809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1058 VOS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENISON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49428-8105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-795-0298
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 104TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-9149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-795-0298
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DUCKWORTH
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
616-795-0298

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6301016570 , 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)





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