Healthcare Provider Details

I. General information

NPI: 1457996845
Provider Name (Legal Business Name): MR. BENJAMIN BRYAN HOLDREDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2019
Last Update Date: 11/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RAYBROOK ST SE STE 103
GRAND RAPIDS MI
49546-7718
US

IV. Provider business mailing address

2040 RAYBROOK ST SE STE 103
GRAND RAPIDS MI
49546-7718
US

V. Phone/Fax

Practice location:
  • Phone: 616-419-4791
  • Fax:
Mailing address:
  • Phone: 616-419-4791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017829
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: