MEDICARE: LIVING WELL RECREATION THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	62081	MI

General Provider Information

NPI Number	:	1700253895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WELL RECREATION THERAPY

Provider Business Mailing Address
First Line	:	1351 SHERMAN ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2613
Country	:	US
Telephone Number	:	616-710-1166
Fax Number	:

Provider Business Practice Location Address
First Line	:	1351 SHERMAN ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2613
Country	:	US
Telephone Number	:	616-710-1166
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED RECREATIONAL THERAPIST
Name	:	MIRANDA M WARD
Credential	:
Telephone Number	:	616-710-1166

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	08/25/2015

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