Healthcare Provider Details

I. General information

NPI: 1932699337
Provider Name (Legal Business Name): LAURA HOCKENBERRY GARDNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 E BELTLINE CT NE
GRAND RAPIDS MI
49525-9494
US

IV. Provider business mailing address

3280 E BELTLINE CT NE
GRAND RAPIDS MI
49525-9494
US

V. Phone/Fax

Practice location:
  • Phone: 616-446-0813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301014494
License Number StateMI

VIII. Authorized Official

Name: LAURA HOCKENBERRY GARDNER
Title or Position: OWNER OPERATOR
Credential:
Phone: 616-446-0813