Healthcare Provider Details

I. General information

NPI: 1306554282
Provider Name (Legal Business Name): GRAND RAPIDS COUNSELING AND CONSULTATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 76TH ST SW STE H4
BYRON CENTER MI
49315-7921
US

IV. Provider business mailing address

769 SUN STONE DR SW
BYRON CENTER MI
49315-8396
US

V. Phone/Fax

Practice location:
  • Phone: 616-780-1243
  • Fax:
Mailing address:
  • Phone: 616-258-6270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLY IBARRA
Title or Position: OWNER
Credential: MA, LPC, SCL
Phone: 616-258-6270