Healthcare Provider Details

I. General information

NPI: 1750690368
Provider Name (Legal Business Name): EMILY FORTUNA MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE STE 120
GRAND RAPIDS MI
49546-5939
US

IV. Provider business mailing address

2200 NEGAUNEE DR SE
GRAND RAPIDS MI
49506-5321
US

V. Phone/Fax

Practice location:
  • Phone: 206-696-8765
  • Fax:
Mailing address:
  • Phone: 206-696-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016255
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: