Healthcare Provider Details

I. General information

NPI: 1205633161
Provider Name (Legal Business Name): CREDA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 ADA PLACE DR SE
GRAND RAPIDS MI
49546-3793
US

IV. Provider business mailing address

977 ADA PLACE DR SE
GRAND RAPIDS MI
49546-3793
US

V. Phone/Fax

Practice location:
  • Phone: 616-295-0691
  • Fax:
Mailing address:
  • Phone: 616-295-0691
  • 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: MARIO GIBSON FRANCISCOTTY
Title or Position: OWNER
Credential: LPC
Phone: 616-295-0691