Healthcare Provider Details

I. General information

NPI: 1114290517
Provider Name (Legal Business Name): 139 EDUCATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E BELTLINE AVE NE SUITE 212
GRAND RAPIDS MI
49525-7045
US

IV. Provider business mailing address

3790 30TH ST SW
GRANDVILLE MI
49418-1602
US

V. Phone/Fax

Practice location:
  • Phone: 800-600-4096
  • Fax:
Mailing address:
  • Phone: 800-600-4096
  • Fax: 800-606-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009353
License Number StateMI

VIII. Authorized Official

Name: DR. TIMOTHY ROYER
Title or Position: OWNER
Credential:
Phone: 616-706-5649