Healthcare Provider Details

I. General information

NPI: 1609327808
Provider Name (Legal Business Name): MIND BODY SOULUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2016
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

5242 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1084
US

V. Phone/Fax

Practice location:
  • Phone: 616-613-6130
  • Fax:
Mailing address:
  • Phone: 616-613-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096853
License Number StateMI

VIII. Authorized Official

Name: ANYSSA GRENDEL
Title or Position: LICENSED MASTERS SOCIAL WORKER
Credential: LMSW
Phone: 616-240-4685