Healthcare Provider Details

I. General information

NPI: 1376178020
Provider Name (Legal Business Name): PRO-ACTIVE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 84TH ST SW
BYRON CENTER MI
49315-9344
US

IV. Provider business mailing address

PO BOX 519
BYRON CENTER MI
49315-0519
US

V. Phone/Fax

Practice location:
  • Phone: 616-292-1995
  • Fax: 616-827-2277
Mailing address:
  • Phone: 616-292-1995
  • Fax: 616-827-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MUSSELMAN
Title or Position: DIRECTOR
Credential: LLP
Phone: 616-292-1995