Basic Information
| Provider Information | |||||||||
| NPI: | 1477827152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANTLE-DOUGLAS | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162587467 | ||||||||
| FaxNumber: | 6162587432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2012 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401011166 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401011166 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.