Healthcare Provider Details

I. General information

NPI: 1548031222
Provider Name (Legal Business Name): SHELBY CAVENDER THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/11/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1010
US

IV. Provider business mailing address

7030 DOGWOOD CT
JENISON MI
49428-8113
US

V. Phone/Fax

Practice location:
  • Phone: 616-648-9235
  • Fax:
Mailing address:
  • Phone: 616-648-9235
  • 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: SHELBY MARIE CAVENDER
Title or Position: PSYCHOTHERAPIST
Credential: LMSW
Phone: 616-648-9235