Healthcare Provider Details

I. General information

NPI: 1891431920
Provider Name (Legal Business Name): RILEY ANNE KORTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

6739 COURTLAND DR NE STE 203
ROCKFORD MI
49341-7217
US

V. Phone/Fax

Practice location:
  • Phone: 616-323-1116
  • Fax:
Mailing address:
  • Phone: 616-323-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851114551
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: