Healthcare Provider Details

I. General information

NPI: 1932924594
Provider Name (Legal Business Name): MANTRA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 PARCHMENT DR SE STE 100
GRAND RAPIDS MI
49546-2307
US

IV. Provider business mailing address

326 EASTMOOR AVE SE
GRAND RAPIDS MI
49546-2227
US

V. Phone/Fax

Practice location:
  • Phone: 616-366-4226
  • Fax:
Mailing address:
  • Phone: 616-581-7687
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MATT DEHOOG
Title or Position: PROFESSIONAL COUNSELOR
Credential: MA, LPC
Phone: 616-366-4226