Healthcare Provider Details

I. General information

NPI: 1114761186
Provider Name (Legal Business Name): RIVERSIDE PSYCHIATRIC SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 44TH ST SE STE 107
GRAND RAPIDS MI
49508-5305
US

IV. Provider business mailing address

5082 BREEZEFIELD DR SE
GRAND RAPIDS MI
49512-9520
US

V. Phone/Fax

Practice location:
  • Phone: 616-425-9666
  • Fax:
Mailing address:
  • Phone: 616-334-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GODFREY ABUYA
Title or Position: MANAGER
Credential: PMHNP
Phone: 616-334-0011