Healthcare Provider Details

I. General information

NPI: 1740154111
Provider Name (Legal Business Name): AUTUMN CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 CASCADE RD SE
GRAND RAPIDS MI
49546-3665
US

IV. Provider business mailing address

4793 WAKEFIELD AVE NE
COMSTOCK PARK MI
49321-8958
US

V. Phone/Fax

Practice location:
  • Phone: 616-277-7533
  • Fax:
Mailing address:
  • Phone: 810-449-9715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number451024603
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: