MEDICARE: LIFE GUIDANCE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1336185032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE GUIDANCE SERVICES

Provider Business Mailing Address
First Line	:	330 EASTERN NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503
Country	:	US
Telephone Number	:	616-776-0891
Fax Number	:	616-233-0718

Provider Business Practice Location Address
First Line	:	1400 LEONARD ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5515
Country	:	US
Telephone Number	:	616-954-1992
Fax Number	:	616-954-1998

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DAN L FOGEL
Credential	:	MA,LLP
Telephone Number	:	616-954-1992

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	06/07/2011

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Directions to “LIFE GUIDANCE SERVICES ” Practice Location

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