Healthcare Provider Details

I. General information

NPI: 1770367237
Provider Name (Legal Business Name): REAL TALK THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 28TH ST. SE SUITE 3, OFFICES C&D
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

599 OAK MEADOW DR
MIDDLEVILLE MI
49333-8478
US

V. Phone/Fax

Practice location:
  • Phone: 231-286-2355
  • Fax:
Mailing address:
  • Phone: 231-286-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS MARK LANGE
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC/LMFT
Phone: 231-286-2355