Healthcare Provider Details

I. General information

NPI: 1760939557
Provider Name (Legal Business Name): CONNIE SARGUNAM LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE STE A
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

5242 PLAINFIELD AVE NE STE A
GRAND RAPIDS MI
49525-1084
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-2200
  • Fax:
Mailing address:
  • Phone: 616-363-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301016618
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: