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General NPI Number Information
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NPI Number | 1669113478
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Entity Type | Individual
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Provider Name | BETHANIE BLACKANN
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Gender | Female
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 3300 36TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-2810
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Country | US
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Telephone | 616-942-2810
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Fax |
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Provider Business Mailing Address
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Address Line | 1277 COBB DR SE APT 3A
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-7164
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Country | US
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Telephone | 313-670-2065
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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