Healthcare Provider Details

I. General information

NPI: 1619647047
Provider Name (Legal Business Name): RAINA AWDISH RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STEVENS ST SW
GRAND RAPIDS MI
49507-1526
US

IV. Provider business mailing address

4575 SE DIXIE HWY
STUART FL
34997-6826
US

V. Phone/Fax

Practice location:
  • Phone: 616-469-4870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: