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General NPI Number Information
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NPI Number | 1568866754
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Entity Type | Organization
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Legal Business Name | FOUNTAIN HILL CENTER -- LAKESHORE OFFICE
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Dates
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Enumeration Date | 10/16/2014
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Last Update Date | 10/16/2014
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Provider Practice Location Address
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Address Line | 534 FOUNTAIN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-3422
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Country | US
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Telephone | 616-456-1178
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 32
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City | NEW ERA
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State | MI
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Zip | 49446-0032
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Country | US
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Telephone | 616-456-1178
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE COORDINATOR
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Name | AMY VAN GUNST
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Credential | M.A., L.P.C.
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Telephone | 616-456-1178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | MI
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