Healthcare Provider Details

I. General information

NPI: 1396010617
Provider Name (Legal Business Name): CHILD & FAMILY THERAPY CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 VINE ST
GOBLES MI
49055-9693
US

IV. Provider business mailing address

114 VINE ST P.O. BOX 373
GOBLES MI
49055-9693
US

V. Phone/Fax

Practice location:
  • Phone: 269-352-3558
  • Fax:
Mailing address:
  • Phone: 269-352-3558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801090517
License Number StateMI

VIII. Authorized Official

Name: GRACHELLE ALYCE SHERBURNE
Title or Position: CLINICAL THERAPIST
Credential: LMSW
Phone: 269-352-3558