Healthcare Provider Details

I. General information

NPI: 1740658673
Provider Name (Legal Business Name): JUSTINE BRAFORD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4127 EMBASSY DR SE
GRAND RAPIDS MI
49546-2418
US

IV. Provider business mailing address

4127 EMBASSY DR SE
GRAND RAPIDS MI
49546-2418
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-3200
  • Fax: 616-264-3201
Mailing address:
  • Phone: 616-264-3200
  • Fax: 616-264-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092797
License Number StateMI

VIII. Authorized Official

Name: JUSTINE BRAFORD
Title or Position: OWNER/PROVIDER
Credential: LMSW
Phone: 616-264-3200