Healthcare Provider Details

I. General information

NPI: 1750277000
Provider Name (Legal Business Name): MIA FLYNN TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CASCADE WEST PKWY SE STE 240
GRAND RAPIDS MI
49546-2166
US

IV. Provider business mailing address

537 HAMPTON LN NW APT 1A
WALKER MI
49534-7818
US

V. Phone/Fax

Practice location:
  • Phone: 616-591-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6351004831
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6351004831
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: