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General NPI Number Information
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NPI Number | 1902471568
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Entity Type | Individual
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Provider Name | ELISE MACKENZIE RICHARDS
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Gender | Female
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Dates
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Enumeration Date | 05/25/2021
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Last Update Date | 05/25/2021
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Provider Practice Location Address
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Address Line | 1115 BALL AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-5904
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Country | US
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Telephone | 616-456-6571
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Fax |
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Provider Business Mailing Address
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Address Line | 1127 52ND AVE APT. C7
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City | ALLENDALE
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State | MI
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Zip | 49401-5904
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Country | US
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Telephone | 517-993-4217
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State | MI
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