Healthcare Provider Details

I. General information

NPI: 1467925222
Provider Name (Legal Business Name): 616 COUNSELING PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CASCADE WEST PKWY SE
GRAND RAPIDS MI
49546-2137
US

IV. Provider business mailing address

550 CASCADE WEST PKWY SE
GRAND RAPIDS MI
49546-2137
US

V. Phone/Fax

Practice location:
  • Phone: 616-930-4123
  • Fax: 616-323-3994
Mailing address:
  • Phone: 616-930-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHAWN GAUTHIER
Title or Position: PARTNER & CLINICAL SOCIAL WORKER
Credential: LMSW, ACSW, CAADC
Phone: 616-930-4123