Healthcare Provider Details

I. General information

NPI: 1942510425
Provider Name (Legal Business Name): LIFE GUIDANCE SERVIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LEONARD STREET NE
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

1147 ARLINGTON NE
GRAND RAPIDS MI
49505
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-1991
  • Fax: 616-954-1998
Mailing address:
  • Phone: 616-954-1991
  • Fax: 616-954-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number681092605
License Number StateMI

VIII. Authorized Official

Name: VANESSA J EDWARDS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 616-954-1991