=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952118515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSCIOUS CONNECTIONS SOUTHWEST MICHIGAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 W ALLEGAN ST
-----------------------------------------------------
City | OTSEGO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49078-1086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-914-8223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 W ALLEGAN ST
-----------------------------------------------------
City | OTSEGO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49078-1086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | RACHAEL GILBERT
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 616-914-8223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------