Healthcare Provider Details

I. General information

NPI: 1558837484
Provider Name (Legal Business Name): MICHELLE MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MONROE AVE NW STE 400
GRAND RAPIDS MI
49503-2293
US

IV. Provider business mailing address

6436 MILLSTREAM LOOP SE
CALEDONIA MI
49316-9179
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-1286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401015215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: