Healthcare Provider Details

I. General information

NPI: 1831819143
Provider Name (Legal Business Name): LIFE WITHOUT FLAWS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/29/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 44TH ST SE STE 301
GRAND RAPIDS MI
49508-5093
US

IV. Provider business mailing address

719 ARDMORE ST SE
GRAND RAPIDS MI
49507-3258
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-5112
  • Fax: 616-259-5112
Mailing address:
  • Phone: 616-780-7664
  • Fax: 616-971-6157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORRAINE BENNETT
Title or Position: PSYCHOLOGIST, PROF. COUNSELOR
Credential: MASTER'S DEGREE
Phone: 616-259-5112