Healthcare Provider Details

I. General information

NPI: 1013294628
Provider Name (Legal Business Name): 139 EDUCATION, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 44TH ST SW
GRANDVILLE MI
49418
US

IV. Provider business mailing address

201 MONROE AVE NW SUITE 300
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 800-600-4096
  • Fax: 800-606-8839
Mailing address:
  • Phone: 800-600-4096
  • Fax: 800-606-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009353
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY ROYER
Title or Position: PROVIDER/AUTHORIZED OFFICIAL
Credential: PSY
Phone: 800-600-4096