Basic Information
| Provider Information | |||||||||
| NPI: | 1699146134 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND RAPIDS THERAPY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 LAKE EASTBROOK BLVD SE | ||||||||
| Address2: | STE 280 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172029123 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 LAKE EASTBROOK BLVD SE | ||||||||
| Address2: | STE 280 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172029123 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER BILLING | ||||||||
| AuthorizedOfficialTelephone: | 5174832461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801088826 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.