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General NPI Number Information
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NPI Number | 1578384558
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Entity Type | Organization
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Legal Business Name | STATE OF MIND GRAND RAPIDS LLC
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Dates
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Enumeration Date | 10/22/2024
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 3450 ALPINE AVE NW STE 207
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City | GRAND RAPIDS
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State | MI
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Zip | 49544-1666
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Country | US
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Telephone | 616-215-0588
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 141541
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City | GRAND RAPIDS
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State | MI
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Zip | 49514
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER, COUNSELOR
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Name | KATELYN WYSOCKI
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Credential | MA, LPC
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Telephone | 616-215-0588
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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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