Healthcare Provider Details

I. General information

NPI: 1982271441
Provider Name (Legal Business Name): MICHAELA MARIE OWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

32 MACK AVE NE
GRAND RAPIDS MI
49503-3616
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 369-312-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: