Healthcare Provider Details

I. General information

NPI: 1629435755
Provider Name (Legal Business Name): RAE GREEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

IV. Provider business mailing address

540 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

V. Phone/Fax

Practice location:
  • Phone: 616-288-6970
  • Fax:
Mailing address:
  • Phone: 616-288-6970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011267
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: