Healthcare Provider Details

I. General information

NPI: 1124474820
Provider Name (Legal Business Name): MELISSA MUIR LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 KENMOOR AVE SE STE 101A
GRAND RAPIDS MI
49546-8626
US

IV. Provider business mailing address

630 KENMOOR AVE SE STE 101A
GRAND RAPIDS MI
49546-8626
US

V. Phone/Fax

Practice location:
  • Phone: 616-446-8436
  • Fax: 616-920-6536
Mailing address:
  • Phone: 616-446-8436
  • Fax: 616-920-6536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361001766
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301016678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: