Healthcare Provider Details

I. General information

NPI: 1376820860
Provider Name (Legal Business Name): THETHIRDCHAIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 MONROE AVE NW SUITE 100
GRAND RAPIDS MI
49503-1452
US

IV. Provider business mailing address

648 MONROE AVE NW SUITE 100
GRAND RAPIDS MI
49503-1452
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-3711
  • Fax: 616-825-6015
Mailing address:
  • Phone: 616-916-3711
  • Fax: 616-825-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SCOTT MCKNIGHT
Title or Position: DIRECTOR, FOUNDER
Credential: LMSW
Phone: 616-916-3711