Healthcare Provider Details

I. General information

NPI: 1023710290
Provider Name (Legal Business Name): MASQUIGON INTEGRATIVE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W WEBSTER AVE
MUSKEGON MI
49440-1294
US

IV. Provider business mailing address

2481 HARDING AVE
MUSKEGON MI
49441-1247
US

V. Phone/Fax

Practice location:
  • Phone: 231-215-3877
  • Fax:
Mailing address:
  • Phone: 231-215-3877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARLA ANN KEVERN
Title or Position: PRACTITIONER
Credential: BCBA, DTLLP, NCSP
Phone: 231-215-3877