Healthcare Provider Details

I. General information

NPI: 1164148789
Provider Name (Legal Business Name): COUNSELING CENTER FOR RESTORATION TRANSFORMATION AND PLAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONROE AVE NW STE 206
GRAND RAPIDS MI
49503-1448
US

IV. Provider business mailing address

1334 LOGAN ST SE
GRAND RAPIDS MI
49506-2554
US

V. Phone/Fax

Practice location:
  • Phone: 616-551-6623
  • Fax:
Mailing address:
  • Phone: 616-551-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER ANIBLE
Title or Position: COUNSELOR
Credential: LMSW, RPT-S
Phone: 616-551-6623