Healthcare Provider Details

I. General information

NPI: 1023660891
Provider Name (Legal Business Name): LORRAINE BENNETT TLLP, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DUSTY LORRAINE PITTMAN

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 44TH ST SE STE 301
GRAND RAPIDS MI
49508-5093
US

IV. Provider business mailing address

6054 IN THE PINES DR SE
GRAND RAPIDS MI
49548-8503
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-5112
  • Fax: 616-971-6157
Mailing address:
  • Phone: 616-432-0787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401020248
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: