Basic Information
| Provider Information | |||||||||
| NPI: | 1477119329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICE | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2566 22 MILE RD NW | ||||||||
| Address2: | |||||||||
| City: | KENT CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493309203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162089337 | ||||||||
| FaxNumber: | 6162089337 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169427294 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6241017318 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 14470467 | 01 | CAQH | OTHER |