Healthcare Provider Details

I. General information

NPI: 1558713388
Provider Name (Legal Business Name): AMPLIFIED LIFE NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7791 BYRON CENTER AVE SW
BYRON CENTER MI
49315-8412
US

IV. Provider business mailing address

7791 BYRON CENTER AVE SW
BYRON CENTER MI
49315-8412
US

V. Phone/Fax

Practice location:
  • Phone: 616-724-6943
  • Fax: 616-499-2077
Mailing address:
  • Phone: 616-724-6943
  • Fax: 616-499-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401003943
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LYLE LABARDEE
Title or Position: PRESIDENT
Credential: LPC
Phone: 616-724-6943