Healthcare Provider Details

I. General information

NPI: 1669037685
Provider Name (Legal Business Name): DISCLOSURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 COLLEGE AVE SE
GRAND RAPIDS MI
49507-3101
US

IV. Provider business mailing address

2017 COLLEGE AVE SE
GRAND RAPIDS MI
49507-3101
US

V. Phone/Fax

Practice location:
  • Phone: 616-634-3301
  • Fax: 616-333-7747
Mailing address:
  • Phone: 616-634-3301
  • Fax: 616-333-7747

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: JAMIE LEE DALTON
Title or Position: OWNER / CEO
Credential: LMSW
Phone: 616-634-3301