MEDICARE: INTO THE WOODS RETREAT

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	251S00000X	Community/Behavioral Health Agency	6801088733	MI

General Provider Information

NPI Number	:	1962876243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTO THE WOODS RETREAT

Provider Business Mailing Address
First Line	:	7178 BUTTERNUT DR
Second Line	:
City	:	WEST OLIVE
State	:	MI
Zip	:	49460-9734
Country	:	US
Telephone Number	:	616-498-0958
Fax Number	:

Provider Business Practice Location Address
First Line	:	7178 BUTTERNUT DR
Second Line	:
City	:	WEST OLIVE
State	:	MI
Zip	:	49460-9734
Country	:	US
Telephone Number	:	616-498-0958
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MERCDES SAURBAUGH
Credential	:	LMSW
Telephone Number	:	616-498-0958

Provider Enumeration Date	:	11/24/2015
Last Update Date	:	11/24/2015

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Directions to “INTO THE WOODS RETREAT ” Practice Location

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