Healthcare Provider Details

I. General information

NPI: 1891206447
Provider Name (Legal Business Name): EASTERN DOOR COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2017
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONROE AVE NW STE 206
GRAND RAPIDS MI
49503-1448
US

IV. Provider business mailing address

792 STRAWBERRY VALLEY AVE NW
COMSTOCK PARK MI
49321-9600
US

V. Phone/Fax

Practice location:
  • Phone: 616-802-0212
  • Fax:
Mailing address:
  • Phone: 616-802-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097205
License Number StateMI

VIII. Authorized Official

Name: NICOLE FIX
Title or Position: MEMBER
Credential: LMSW
Phone: 616-802-0212