Healthcare Provider Details

I. General information

NPI: 1821577156
Provider Name (Legal Business Name): INNER X SECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 PARCHMENT DR SE STE 100
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

826 PARCHMENT DR SE STE 100
GRAND RAPIDS MI
49546-2307
US

V. Phone/Fax

Practice location:
  • Phone: 616-326-1645
  • Fax:
Mailing address:
  • Phone: 616-326-1645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401012142
License Number StateMI

VIII. Authorized Official

Name: MRS. LARA SCHAIBLE
Title or Position: OWNER
Credential: MA, LPC
Phone: 616-617-0396