MEDICARE: CHILDHOOD BEHAVIOR CONSULTING SERVICES

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	1041S0200X	School Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1700359478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDHOOD BEHAVIOR CONSULTING SERVICES

Provider Business Mailing Address
First Line	:	5580 HIGHBURY DR SE
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-7738
Country	:	US
Telephone Number	:	616-443-7009
Fax Number	:

Provider Business Practice Location Address
First Line	:	4829 E BELTLINE AVE NE STE 303
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9350
Country	:	US
Telephone Number	:	616-443-7009
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	CORTNEY RAE DUFFNER
Credential	:	LMSW
Telephone Number	:	616-443-7009

Provider Enumeration Date	:	01/05/2019
Last Update Date	:	01/05/2019

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