Healthcare Provider Details

I. General information

NPI: 1184054652
Provider Name (Legal Business Name): ADOLESCENT AND FAMILY BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 02/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE #258
GRAND RAPIDS MI
49546-5938
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: 800-219-5205
Mailing address:
  • Phone: 616-719-0194
  • Fax: 800-219-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015520
License Number StateMI

VIII. Authorized Official

Name: DR. VALENCIA AGNEW
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 616-719-0194