Healthcare Provider Details

I. General information

NPI: 1407252232
Provider Name (Legal Business Name): VR THERAPY AND COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 LEONARD ST NE
GRAND RAPIDS MI
49505-6438
US

IV. Provider business mailing address

1618 LEONARD ST NE
GRAND RAPIDS MI
49505-6438
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-9049
  • Fax:
Mailing address:
  • Phone: 616-988-9049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL260765
License Number StateMI

VIII. Authorized Official

Name: THOMAS JAY OVERLY
Title or Position: SOCIAL WORKER
Credential:
Phone: 616-988-9049