=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295618635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTICITY RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2025
-----------------------------------------------------
Last Update Date | 10/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 CASCADE RD SE STE 102
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-3665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-638-7408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 CASCADE RD SE STE 102
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-3665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-638-7408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | JUSTYNE LEE ORTQUIST
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 616-638-7408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------