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General NPI Number Information
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NPI Number | 1679899280
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Entity Type | Organization
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Legal Business Name | GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC
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Dates
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Enumeration Date | 04/08/2010
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Last Update Date | 04/14/2011
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Provider Practice Location Address
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Address Line | 4519 CASCADE RD SE SUITE 3
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3666
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Country | US
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Telephone | 616-949-6262
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Fax | 616-425-2003
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Provider Business Mailing Address
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Address Line | 4519 CASCADE RD SE SUITE 3
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3666
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Country | US
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Telephone | 616-949-6262
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Fax | 616-425-2003
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MS. CAROLYN H CARINO
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Credential | LMSW ACSW SPADA
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Telephone | 616-949-6262
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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 | 680103034469
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License Number State | MI
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