Healthcare Provider Details

I. General information

NPI: 1942689708
Provider Name (Legal Business Name): THE SHORELINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16925 ABILITY WAY
GRAND HAVEN MI
49417-9325
US

IV. Provider business mailing address

16925 ABILITY WAY
GRAND HAVEN MI
49417-9325
US

V. Phone/Fax

Practice location:
  • Phone: 616-935-7606
  • Fax: 616-935-7607
Mailing address:
  • Phone: 616-935-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014390
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAN RADLEY
Title or Position: OWNER
Credential:
Phone: 616-935-7606