Healthcare Provider Details

I. General information

NPI: 1710615794
Provider Name (Legal Business Name): RETREAT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 E BELTLINE AVE NE BUILDING #1; SUITE 4
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

4867 E BELTLINE AVE NE BUILDING #1; SUITE 4
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-232-6050
  • Fax:
Mailing address:
  • Phone: 616-232-6050
  • 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: TRAVIS GORDON
Title or Position: OWNER
Credential: LPC
Phone: 616-514-7924