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General NPI Number Information
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NPI Number | 1407252232
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Entity Type | Organization
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Legal Business Name | VR THERAPY AND COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 11/05/2014
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Last Update Date | 11/05/2014
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Provider Practice Location Address
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Address Line | 1618 LEONARD ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-6438
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Country | US
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Telephone | 616-988-9049
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Fax |
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Provider Business Mailing Address
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Address Line | 1618 LEONARD ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-6438
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Country | US
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Telephone | 616-988-9049
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | THOMAS JAY OVERLY
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Credential |
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Telephone | 616-988-9049
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L260765
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License Number State | MI
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