Healthcare Provider Details

I. General information

NPI: 1790663359
Provider Name (Legal Business Name): COLBY AUSTIN-JOHNSON WHITAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4829 E BELTLINE AVE NE STE 101
GRAND RAPIDS MI
49525-9349
US

IV. Provider business mailing address

2560 ROSEWATER DR NE UNIT 220
GRAND RAPIDS MI
49525-2981
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-8215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851120660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: