Basic Information
| Provider Information | |||||||||
| NPI: | 1811330251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOPE NETWORK - REHABILITATION SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3075 ORCHARD VISTA DR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163018000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1490 E BELTLINE AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495064336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400040 | ||||||||
| FaxNumber: | 6169408151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6163018000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOPE NETWORK - REHABILITATION SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.