Healthcare Provider Details

I. General information

NPI: 1396353090
Provider Name (Legal Business Name): BETH MELLEMA COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2020
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE STE 255
GRAND RAPIDS MI
49506-4362
US

IV. Provider business mailing address

2181 ENGLESIDE DR SE
GRAND RAPIDS MI
49546-6224
US

V. Phone/Fax

Practice location:
  • Phone: 616-947-4440
  • Fax:
Mailing address:
  • Phone: 616-240-6668
  • Fax:

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: ELIZABETH GARDNER
Title or Position: OWNER
Credential: LMSW
Phone: 616-240-6668