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General NPI Number Information
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NPI Number | 1205633161
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Entity Type | Organization
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Legal Business Name | CREDA PLLC
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Dates
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Enumeration Date | 02/27/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 977 ADA PLACE DR SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3793
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Country | US
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Telephone | 616-295-0691
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Fax |
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Provider Business Mailing Address
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Address Line | 977 ADA PLACE DR SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3793
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Country | US
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Telephone | 616-295-0691
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARIO GIBSON FRANCISCOTTY
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Credential | LPC
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Telephone | 616-295-0691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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