Healthcare Provider Details

I. General information

NPI: 1457810178
Provider Name (Legal Business Name): NATALIE REIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 FULLER AVE NE STE 203
GRAND RAPIDS MI
49505-3458
US

IV. Provider business mailing address

2920 FULLER AVE NE STE 203
GRAND RAPIDS MI
49505-3458
US

V. Phone/Fax

Practice location:
  • Phone: 616-301-5945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023714
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: