Basic Information
| Provider Information | |||||||||
| NPI: | 1063061109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRASSINGTON | ||||||||
| FirstName: | CONNOR | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163363909 | ||||||||
| FaxNumber: | 6163368830 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164104445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401017538 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401222483 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.