Healthcare Provider Details

I. General information

NPI: 1215577226
Provider Name (Legal Business Name): CHARLIE MARIE PLANCK BCBA LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2787 WILSON AVE NW
GRAND RAPIDS MI
49534-7510
US

IV. Provider business mailing address

646 TWIN LAKE DR
HASTINGS MI
49058-7416
US

V. Phone/Fax

Practice location:
  • Phone: 616-915-2066
  • Fax:
Mailing address:
  • Phone: 269-355-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001971
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: