Healthcare Provider Details

I. General information

NPI: 1619421880
Provider Name (Legal Business Name): BREANNE KORTMAN LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNE BERG LLMSW

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 E APPLE AVE
MUSKEGON MI
49442-3466
US

IV. Provider business mailing address

376 E APPLE AVE
MUSKEGON MI
49442-3466
US

V. Phone/Fax

Practice location:
  • Phone: 231-724-3502
  • Fax: 231-724-4545
Mailing address:
  • Phone: 231-724-3502
  • Fax: 231-724-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6801101631
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801101631
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: