Healthcare Provider Details

I. General information

NPI: 1144989146
Provider Name (Legal Business Name): THEA WOODNORTH COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RAYBROOK ST SE STE 301D
GRAND RAPIDS MI
49546-7775
US

IV. Provider business mailing address

1539 BLYTHE CT NW
GRAND RAPIDS MI
49504-2530
US

V. Phone/Fax

Practice location:
  • Phone: 616-304-0274
  • Fax: 517-323-9531
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CATHY GALLEGOS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 517-483-2461