Healthcare Provider Details

I. General information

NPI: 1437464229
Provider Name (Legal Business Name): HORSE PLAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 NILES RD
SAINT JOSEPH MI
49085-3338
US

IV. Provider business mailing address

2820 NILES RD
SAINT JOSEPH MI
49085-3338
US

V. Phone/Fax

Practice location:
  • Phone: 269-405-0653
  • Fax:
Mailing address:
  • Phone: 269-405-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013553
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801069783
License Number StateMI

VIII. Authorized Official

Name: KRISTINE PROCTOR
Title or Position: OWNER
Credential: LMSW
Phone: 269-405-0653