Healthcare Provider Details

I. General information

NPI: 1396158002
Provider Name (Legal Business Name): HEATHER MAYLE LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE RESEARCH DEPARTMENT
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

100 CHERRY ST SE RESEARCH DEPARTMENT
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax: 616-940-5362
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-940-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: