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General NPI Number Information
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NPI Number | 1114290517
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Entity Type | Organization
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Legal Business Name | 139 EDUCATION, LLC
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Dates
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Enumeration Date | 02/15/2012
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Last Update Date | 02/15/2012
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Provider Practice Location Address
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Address Line | 1971 E BELTLINE AVE NE SUITE 212
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-7045
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Country | US
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Telephone | 800-600-4096
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Fax |
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Provider Business Mailing Address
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Address Line | 3790 30TH ST SW
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City | GRANDVILLE
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State | MI
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Zip | 49418-1602
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Country | US
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Telephone | 800-600-4096
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Fax | 800-606-8839
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY ROYER
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Credential |
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Telephone | 616-706-5649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301009353
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License Number State | MI
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