Healthcare Provider Details

I. General information

NPI: 1497006837
Provider Name (Legal Business Name): MIRELLA IVELLISE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 WOODBURN DR SE
GRAND RAPIDS MI
49546-4385
US

IV. Provider business mailing address

542 EASTERN AVE NE APT 1
GRAND RAPIDS MI
49503-1809
US

V. Phone/Fax

Practice location:
  • Phone: 616-340-5387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: