Healthcare Provider Details

I. General information

NPI: 1295618635
Provider Name (Legal Business Name): AUTHENTICITY RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 10/25/2025
Certification Date: 10/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CASCADE RD SE STE 102
GRAND RAPIDS MI
49546-3665
US

IV. Provider business mailing address

4500 CASCADE RD SE STE 102
GRAND RAPIDS MI
49546-3665
US

V. Phone/Fax

Practice location:
  • Phone: 616-638-7408
  • Fax:
Mailing address:
  • Phone: 616-638-7408
  • 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 Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: JUSTYNE LEE ORTQUIST
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 616-638-7408