Healthcare Provider Details

I. General information

NPI: 1144580077
Provider Name (Legal Business Name): ISETHENA PRESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E SUITE 126
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

PO BOX 1767
GRAND RAPIDS MI
49501-1767
US

V. Phone/Fax

Practice location:
  • Phone: 616-218-9903
  • Fax: 616-459-9059
Mailing address:
  • Phone: 616-235-2090
  • Fax: 616-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TRACY M MCGEE
Title or Position: OWNER
Credential: MA LLP
Phone: 616-218-9903