Healthcare Provider Details

I. General information

NPI: 1336185032
Provider Name (Legal Business Name): LIFE GUIDANCE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

330 EASTERN NE
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-1992
  • Fax: 616-954-1998
Mailing address:
  • Phone: 616-776-0891
  • Fax: 616-233-0718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN L FOGEL
Title or Position: EXECUTIVE DIRECTOR
Credential: MA,LLP
Phone: 616-954-1992