Healthcare Provider Details

I. General information

NPI: 1487291217
Provider Name (Legal Business Name): HEIDI NERESON-BOTT LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI ENGWERT

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 TROWBRIDGE ST NE
GRAND RAPIDS MI
49503-1885
US

IV. Provider business mailing address

2601 HAGUE AVE SW
WYOMING MI
49519-2335
US

V. Phone/Fax

Practice location:
  • Phone: 616-499-7711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016112
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: