Healthcare Provider Details

I. General information

NPI: 1114615572
Provider Name (Legal Business Name): PORTAGE FAMILY HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 PORTAGE RD STE B
PORTAGE MI
49002-1774
US

IV. Provider business mailing address

5900 PORTAGE RD STE B
PORTAGE MI
49002-1774
US

V. Phone/Fax

Practice location:
  • Phone: 269-888-3839
  • Fax:
Mailing address:
  • Phone: 269-888-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: JESSICA GRIFFIOEN
Title or Position: OWNER
Credential: MA, LLPC
Phone: 269-888-3839