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General NPI Number Information
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NPI Number | 1861665473
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Entity Type | Organization
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Legal Business Name | RAYBROOK COUNSELING GROUP LLC
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Dates
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Enumeration Date | 04/04/2008
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Last Update Date | 04/04/2008
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Provider Practice Location Address
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Address Line | 2020 RAYBROOK ST SE SUITE 104-A
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7717
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Country | US
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Telephone | 616-977-5200
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Fax | 866-721-6199
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Provider Business Mailing Address
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Address Line | 2020 RAYBROOK ST SE SUITE 104-A
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7717
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Country | US
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Telephone | 616-977-5200
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Fax | 866-721-6199
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Authorized Official
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Title or Position | OWNER/EXECUTIVE DIRECTOR
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Name | MRS. MARY ELLEN RAE BERTLING-SAFFORD
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Credential | MA, LPC
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Telephone | 616-977-5200
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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 | 6401007799
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License Number State | MI
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