Healthcare Provider Details

I. General information

NPI: 1851642367
Provider Name (Legal Business Name): WEST MICHIGAN THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 COMMERCE ST 2333 JARMAN ST
MUSKEGON MI
49441
US

IV. Provider business mailing address

1823 COMMERCE ST SAME
MUSKEGON MI
49441
US

V. Phone/Fax

Practice location:
  • Phone: 231-728-2138
  • Fax: 231-722-4771
Mailing address:
  • Phone: 231-728-2138
  • Fax: 231-722-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: RANDAL EUGENE DAME
Title or Position: CERTIFIED ALCOHOL & DRUG COUNSELO
Credential: ASSOCIATES CADC-M
Phone: 231-728-2138