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General NPI Number Information
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NPI Number | 1003595448
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Entity Type | Organization
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Legal Business Name | RIVERSIDE COUNSELING, LLC
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 8618 BROWER LAKE DR NE
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City | ROCKFORD
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State | MI
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Zip | 49341-8320
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Country | US
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Telephone | 989-274-7219
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Fax |
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Provider Business Mailing Address
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Address Line | 8618 BROWER LAKE DR NE
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City | ROCKFORD
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State | MI
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Zip | 49341-8320
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Country | US
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Telephone | 989-274-7219
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. BONNIE J DYKSTRA
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Credential | PH.D
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Telephone | 989-274-7219
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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