{
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"OrgName": "ADOLESCENT AND FAMILY BEHAVIORAL HEALTH SERVICES",
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"FirstLineMailingAddress": "2566 WOODMEADOW DR SE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GRAND RAPIDS",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49546-8031",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "616-719-0194",
"MailingAddressFaxNumber": "800-219-5205",
"FirstLinePracticeLocationAddress": "3501 LAKE EASTBROOK BLVD SE",
"SecondLinePracticeLocationAddress": "#258",
"PracticeLocationAddressCityName": "GRAND RAPIDS",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "616-719-0194",
"PracticeLocationAddressFaxNumber": "800-219-5205",
"EnumerationDate": "11/20/2013",
"LastUpdateDate": "02/09/2019",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "AGNEW",
"AuthorizedOfficialFirstName": "VALENCIA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PSYCHOLOGIST",
"AuthorizedOfficialNamePrefix": "DR.",
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"AuthorizedOfficialCredential": "PHD",
"AuthorizedOfficialTelephoneNumber": "616-719-0194",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Psychologist",
"LicenseNumber": "6301015520",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}