Healthcare Provider Details

I. General information

NPI: 1508096710
Provider Name (Legal Business Name): BETHANY CHRISTIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

IV. Provider business mailing address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-7617
  • Fax:
Mailing address:
  • Phone: 616-224-7617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6801091422
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801091422
License Number StateMI

VIII. Authorized Official

Name: STEPHANIE JO CARLTON
Title or Position: THERAPIST
Credential: LLMSW
Phone: 616-224-7617