Healthcare Provider Details

I. General information

NPI: 1043652928
Provider Name (Legal Business Name): FAMILY OUTREACH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 COLRAIN ST SW
GRAND RAPIDS MI
49548-1013
US

IV. Provider business mailing address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507-2459
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-1479
  • Fax: 616-988-1493
Mailing address:
  • Phone: 616-988-1479
  • Fax: 616-988-1493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHERI LANDON
Title or Position: CLINICIAN
Credential: LLMSW
Phone: 616-988-1479