Healthcare Provider Details

I. General information

NPI: 1396668893
Provider Name (Legal Business Name): LEONIE GRACE HARZMAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RAYBROOK ST SE STE 103
GRAND RAPIDS MI
49546-7718
US

IV. Provider business mailing address

2040 RAYBROOK ST SE STE 103
GRAND RAPIDS MI
49546-7718
US

V. Phone/Fax

Practice location:
  • Phone: 616-320-4689
  • Fax: 616-369-5750
Mailing address:
  • Phone: 616-320-4689
  • Fax: 616-369-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010245
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: