Provider Demographics
NPI:1285086900
Name:BRAVE GRAND RAPIDS LLC
Entity type:Organization
Organization Name:BRAVE GRAND RAPIDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:616-419-8628
Mailing Address - Street 1:103 COLLEGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5921
Mailing Address - Country:US
Mailing Address - Phone:616-419-8628
Mailing Address - Fax:
Practice Address - Street 1:103 COLLEGE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5921
Practice Address - Country:US
Practice Address - Phone:616-419-8628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015446101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty