Healthcare Provider Details

I. General information

NPI: 1396554234
Provider Name (Legal Business Name): MADISON MARIE INGERSOLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 44TH ST SE STE 100
GRAND RAPIDS MI
49508-4633
US

IV. Provider business mailing address

3920 KIOWA CT SW
GRANDVILLE MI
49418-1841
US

V. Phone/Fax

Practice location:
  • Phone: 616-320-1096
  • Fax:
Mailing address:
  • Phone: 616-320-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: