Healthcare Provider Details

I. General information

NPI: 1861045775
Provider Name (Legal Business Name): RELIANCE COMMUNITY CARE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 RAYBROOK ST SE STE 100
GRAND RAPIDS MI
49546-5782
US

IV. Provider business mailing address

2100 RAYBROOK ST SE STE 203
GRAND RAPIDS MI
49546-5783
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-1555
  • Fax: 616-954-1520
Mailing address:
  • Phone: 616-954-1518
  • Fax: 616-954-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH M MATHESONNORTHERN
Title or Position: BILLING SPECIALIST
Credential: ABA
Phone: 616-954-1518