Healthcare Provider Details

I. General information

NPI: 1992695563
Provider Name (Legal Business Name): POTENTIAL LLP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 PLAINFIELD AVE NE STE 100
GRAND RAPIDS MI
49525-2087
US

IV. Provider business mailing address

144 OAKES ST SW APT 1307
GRAND RAPIDS MI
49503-3148
US

V. Phone/Fax

Practice location:
  • Phone: 616-828-2788
  • Fax: 616-608-4657
Mailing address:
  • Phone: 616-828-2788
  • Fax: 616-608-4657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MILLER
Title or Position: OWNER/PROVIDER
Credential:
Phone: 616-828-2788