Healthcare Provider Details

I. General information

NPI: 1861665473
Provider Name (Legal Business Name): RAYBROOK COUNSELING GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE SUITE 104-A
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

2020 RAYBROOK ST SE SUITE 104-A
GRAND RAPIDS MI
49546-7717
US

V. Phone/Fax

Practice location:
  • Phone: 616-977-5200
  • Fax: 866-721-6199
Mailing address:
  • Phone: 616-977-5200
  • Fax: 866-721-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401007799
License Number StateMI

VIII. Authorized Official

Name: MRS. MARY ELLEN RAE BERTLING-SAFFORD
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: MA, LPC
Phone: 616-977-5200