Healthcare Provider Details

I. General information

NPI: 1336668698
Provider Name (Legal Business Name): CLAYSTONE CLINICAL ASSOCIATES PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 CAMELOT CT SE STE E
GRAND RAPIDS MI
49546-6083
US

IV. Provider business mailing address

2401 CAMELOT CT SE STE E
GRAND RAPIDS MI
49546-6083
US

V. Phone/Fax

Practice location:
  • Phone: 616-648-2289
  • Fax: 616-949-3018
Mailing address:
  • Phone: 616-949-7460
  • Fax: 616-949-3018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROLE CHISHOLM
Title or Position: CEO
Credential: MSW
Phone: 616-949-7460