Healthcare Provider Details

I. General information

NPI: 1891573382
Provider Name (Legal Business Name): LAUREN BONNELL MA MLP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E BELTLINE AVE NE STE 1063526
GRAND RAPIDS MI
49525-7045
US

IV. Provider business mailing address

1971 E BELTLINE AVE NE STE 106
GRAND RAPIDS MI
49525-7045
US

V. Phone/Fax

Practice location:
  • Phone: 616-260-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAUREN BONNELL
Title or Position: OWNER
Credential: MA MLP
Phone: 616-260-5400