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General NPI Number Information
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NPI Number | 1689631251
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Entity Type | Individual
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Provider Name | BETH JOY BLACKBIRD PSYD
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Gender | Female
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Dates
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Enumeration Date | 04/27/2006
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Last Update Date | 03/08/2024
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Provider Practice Location Address
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Address Line | 235 WEALTHY ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-5299
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Country | US
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Telephone | 616-242-9201
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Fax | 616-451-9513
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Provider Business Mailing Address
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Address Line | 235 WEALTHY ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-5247
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Country | US
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Telephone | 616-840-8668
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Fax | 616-840-9762
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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 | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number | 6301010300
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License Number State | MI
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