Healthcare Provider Details

I. General information

NPI: 1659843340
Provider Name (Legal Business Name): BRIANNA JOY HENIGE MA, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 3 MILE RD NW
GRAND RAPIDS MI
49544-8209
US

IV. Provider business mailing address

640 3 MILE RD NW STE G
GRAND RAPIDS MI
49544-8209
US

V. Phone/Fax

Practice location:
  • Phone: 800-693-1916
  • Fax:
Mailing address:
  • Phone: 800-693-1916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362005050
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361007308
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301017750
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007308
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: