Healthcare Provider Details

I. General information

NPI: 1053833384
Provider Name (Legal Business Name): BROOKE C BEDNAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

IV. Provider business mailing address

901 WEALTHY ST SE
GRAND RAPIDS MI
49506-1514
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2522
  • Fax:
Mailing address:
  • Phone: 810-569-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: