Healthcare Provider Details

I. General information

NPI: 1073722542
Provider Name (Legal Business Name): MARY BETH CHILD LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 PLAINFIELD AVE NE SUITE C
GRAND RAPIDS MI
49525-1644
US

IV. Provider business mailing address

4701 PLAINFIELD AVE NE SUITE C
GRAND RAPIDS MI
49525-1644
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-3398
  • Fax: 616-361-3395
Mailing address:
  • Phone: 616-361-3398
  • Fax: 616-361-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301010573
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: