Healthcare Provider Details

I. General information

NPI: 1689329120
Provider Name (Legal Business Name): THIRD COAST COUNSELING & CONSULTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY ST SE STE 236
GRAND RAPIDS MI
49506-2755
US

IV. Provider business mailing address

1514 WEALTHY ST SE STE 236
GRAND RAPIDS MI
49506-2755
US

V. Phone/Fax

Practice location:
  • Phone: 616-328-3756
  • Fax: 616-284-2133
Mailing address:
  • Phone: 616-328-3756
  • Fax: 616-284-2133

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: MELISSA J LANGLEY
Title or Position: PRINCIPLE
Credential: LPC
Phone: 616-328-3756