Healthcare Provider Details

I. General information

NPI: 1972002111
Provider Name (Legal Business Name): LLC BEHAVIOR SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 MILLBROOK ST SE
GRAND RAPIDS MI
49508-2636
US

IV. Provider business mailing address

1960 MILLBROOK ST SE
GRAND RAPIDS MI
49508-2636
US

V. Phone/Fax

Practice location:
  • Phone: 616-633-3700
  • Fax: 616-930-4640
Mailing address:
  • Phone: 616-633-3700
  • Fax: 616-930-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-00112
License Number StateMI

VIII. Authorized Official

Name: LARRY MITCHELL
Title or Position: EXECUTIVE DIRECTOR PROGRAM MANAGER
Credential: MA. CAADC. SPADA.
Phone: 616-633-3700