Healthcare Provider Details

I. General information

NPI: 1255996575
Provider Name (Legal Business Name): THE FAMILY THERAPY PLACE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 FRONT AVE NW
GRAND RAPIDS MI
49504-5366
US

IV. Provider business mailing address

430 FAIRFIELD AVE NW
GRAND RAPIDS MI
49504-4648
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-7001
  • Fax:
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: TRACY THOMPSON
Title or Position: OWNER
Credential: LPC
Phone: 616-916-7001