Healthcare Provider Details

I. General information

NPI: 1306334115
Provider Name (Legal Business Name): ENDEAVOR BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MICHIGAN ST. NW #3520
GRAND RAPIDS MI
49501-3520
US

IV. Provider business mailing address

225 MICHIGAN ST. NW #3520
GRAND RAPIDS MI
49501-3520
US

V. Phone/Fax

Practice location:
  • Phone: 248-798-0474
  • Fax:
Mailing address:
  • Phone: 248-798-0474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: BETH A BOOGHOLT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 248-798-0474