=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164306478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBUILD COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2025
-----------------------------------------------------
Last Update Date | 08/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 E RAILWAY ST
-----------------------------------------------------
City | COLEMAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-890-9283
-----------------------------------------------------
Fax | 929-596-7897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 E RAILWAY ST
-----------------------------------------------------
City | COLEMAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-890-9283
-----------------------------------------------------
Fax | 929-596-7897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY BROCKSCHMIDT
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 616-890-9283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------