Healthcare Provider Details

I. General information

NPI: 1124584545
Provider Name (Legal Business Name): REBECCA NELSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE STE 280
GRAND RAPIDS MI
49546-5940
US

IV. Provider business mailing address

3920 MARLBORO ST NW
GRAND RAPIDS MI
49534-4537
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-6638
  • Fax:
Mailing address:
  • Phone: 616-828-8591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: REBECCA E NELSON
Title or Position: OWNER/THERAPIST
Credential: LMSW
Phone: 616-202-6638