Provider Demographics
NPI:1316268923
Name:LOVE, BETSY MARIE
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:MARIE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 E PARIS AVE SE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2426
Mailing Address - Country:US
Mailing Address - Phone:616-805-9725
Mailing Address - Fax:
Practice Address - Street 1:1540 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1514
Practice Address - Country:US
Practice Address - Phone:818-244-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006678101YP2500X
101Y00000X, 101YM0800X, 225400000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist