Healthcare Provider Details

I. General information

NPI: 1942169040
Provider Name (Legal Business Name): THE BLOSSOM COUNSELING CENTER FOR PERSONAL GROWTH AND DEVELOPMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4829 E BELTLINE AVE NE STE 101
GRAND RAPIDS MI
49525-9349
US

IV. Provider business mailing address

5110 28TH ST SE # 1145
GRAND RAPIDS MI
49512-2049
US

V. Phone/Fax

Practice location:
  • Phone: 616-284-1138
  • Fax:
Mailing address:
  • Phone: 616-284-1138
  • 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: SHAYNE DELANA MCNICHOLS
Title or Position: THERAPIST
Credential: LMSW
Phone: 616-284-1138