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General NPI Number Information
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NPI Number | 1700253895
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Entity Type | Organization
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Legal Business Name | LIVING WELL RECREATION THERAPY
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 1351 SHERMAN ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-2613
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Country | US
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Telephone | 616-710-1166
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Fax |
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Provider Business Mailing Address
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Address Line | 1351 SHERMAN ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-2613
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Country | US
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Telephone | 616-710-1166
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Fax |
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Authorized Official
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Title or Position | CERTIFIED RECREATIONAL THERAPIST
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Name | MIRANDA M WARD
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Credential |
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Telephone | 616-710-1166
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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 | 62081
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License Number State | MI
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