Healthcare Provider Details

I. General information

NPI: 1912416181
Provider Name (Legal Business Name): INTENTIONAL LIFE COUNSELING & ADDICTIONS TREATMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 MICHIGAN ST NE STE 3
GRAND RAPIDS MI
49503-2028
US

IV. Provider business mailing address

1444 MICHIGAN ST NE STE 3
GRAND RAPIDS MI
49503-2028
US

V. Phone/Fax

Practice location:
  • Phone: 616-734-9745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: THAVONE HUINIL
Title or Position: OWNER
Credential: MSW
Phone: 616-734-9745