Healthcare Provider Details

I. General information

NPI: 1811305246
Provider Name (Legal Business Name): BENJAMIN REISTERER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 KENMOOR AVE SE SUITE B
GRAND RAPIDS MI
49546-2304
US

IV. Provider business mailing address

6916 NORTHLAND DR NE
ROCKFORD MI
49341-9609
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-0650
  • Fax:
Mailing address:
  • Phone: 616-460-0871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: