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General NPI Number Information
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NPI Number | 1104202209
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Entity Type | Organization
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Legal Business Name | HOMEWARD BOUND THERAPEUTIC SERVICES
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Dates
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Enumeration Date | 07/31/2015
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Last Update Date | 07/31/2015
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Provider Practice Location Address
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Address Line | 436 44TH ST SE SUITE C
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-4371
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Country | US
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Telephone | 616-560-0019
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Fax | 616-233-0630
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Provider Business Mailing Address
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Address Line | 1521 PROVIDENCE COVE CT
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City | BYRON CENTER
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State | MI
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Zip | 49315-9149
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Country | US
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Telephone | 616-560-0019
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Fax | 616-233-0630
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MR. RONALD L GROOTERS
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Credential | LMSW, ACSW
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Telephone | 616-560-0019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6801061511
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License Number State | MI
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