Healthcare Provider Details

I. General information

NPI: 1730565243
Provider Name (Legal Business Name): GRACE BOYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 LEONARD ST NE
GRAND RAPIDS MI
49503-1138
US

IV. Provider business mailing address

235 CALKINS AVE SE # 1
GRAND RAPIDS MI
49506-1519
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-2021
  • Fax:
Mailing address:
  • Phone: 269-352-3241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1203
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801100042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: