Healthcare Provider Details

I. General information

NPI: 1992184287
Provider Name (Legal Business Name): RENEE HERBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2566 WOODMEADOW DRIVE SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2566 WOODMEADOW DR SE
GRAND RAPIDS MI
49546-8031
US

V. Phone/Fax

Practice location:
  • Phone: 616-719-0194
  • Fax:
Mailing address:
  • Phone: 616-719-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010033
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: