Healthcare Provider Details

I. General information

NPI: 1285086900
Provider Name (Legal Business Name): BRAVE GRAND RAPIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 COLLEGE AVE SE
GRAND RAPIDS MI
49503-5921
US

IV. Provider business mailing address

103 COLLEGE AVE SE
GRAND RAPIDS MI
49503-5921
US

V. Phone/Fax

Practice location:
  • Phone: 616-419-8628
  • Fax:
Mailing address:
  • Phone: 616-419-8628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015446
License Number StateMI

VIII. Authorized Official

Name: MRS. ALLISON KYLE WALDRON
Title or Position: MANAGER
Credential: LLPC
Phone: 616-419-8628