Healthcare Provider Details

I. General information

NPI: 1104861483
Provider Name (Legal Business Name): CHARLENE MARIE HARABURDA MA, LLP, RSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 68TH ST SE
GRAND RAPIDS MI
49548-6924
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-5180
  • Fax:
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: