Healthcare Provider Details

I. General information

NPI: 1497291603
Provider Name (Legal Business Name): EDWARD GEORGE BALLANCE JR. MACP, MAC, LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4467 CASCADE RD SE STE 4469
GRAND RAPIDS MI
49546-3776
US

IV. Provider business mailing address

4467 CASCADE RD SE STE 4469
GRAND RAPIDS MI
49546-3776
US

V. Phone/Fax

Practice location:
  • Phone: 616-648-3943
  • Fax:
Mailing address:
  • Phone: 616-648-3943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: