Basic Information
| Provider Information | |||||||||
| NPI: | 1013294628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 139 EDUCATION, LLC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEUROCORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 MONROE AVE NW | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006004096 | ||||||||
| FaxNumber: | 8006068839 | ||||||||
| Practice Location | |||||||||
| Address1: | 3148 44TH ST SW | ||||||||
| Address2: | |||||||||
| City: | GRANDVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006004096 | ||||||||
| FaxNumber: | 8006068839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROYER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8006004096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | PSY | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301009353 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0D14689 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |