MEDICARE: INTENTIONAL LIFE COUNSELING & ADDICTIONS TREATMENT PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1912416181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENTIONAL LIFE COUNSELING & ADDICTIONS TREATMENT PLLC

Provider Business Mailing Address
First Line	:	1444 MICHIGAN ST NE STE 3
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1444 MICHIGAN ST NE STE 3
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2028
Country	:	US
Telephone Number	:	616-734-9745
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	THAVONE HUINIL
Credential	:	MSW
Telephone Number	:	616-734-9745

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	09/20/2017

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