Healthcare Provider Details

I. General information

NPI: 1467986190
Provider Name (Legal Business Name): KRISTINAS THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 OLD 28TH ST SE SUITE A
GRAND RAPIDS MI
49546-6937
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 616-710-3170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093733
License Number StateMI

VIII. Authorized Official

Name: MARY BETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788