Healthcare Provider Details

I. General information

NPI: 1356392880
Provider Name (Legal Business Name): CTED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

IV. Provider business mailing address

1003 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-7700
  • Fax: 616-957-7773
Mailing address:
  • Phone: 616-957-7700
  • Fax: 616-957-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ROBINSON
Title or Position: CREDENTIALING CONTACT
Credential:
Phone: 239-791-6363