Healthcare Provider Details

I. General information

NPI: 1528361060
Provider Name (Legal Business Name): TOUCHSTONE INNOVARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

IV. Provider business mailing address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-0255
  • Fax: 616-242-6057
Mailing address:
  • Phone: 616-459-0255
  • Fax: 616-242-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6801090829
License Number StateMI

VIII. Authorized Official

Name: MISS SHANNON MARIE MULLETT
Title or Position: CLINICIAN
Credential: LMSW
Phone: 616-459-0255