Provider Demographics
NPI:1699146134
Name:GRAND RAPIDS THERAPY PLLC
Entity type:Organization
Organization Name:GRAND RAPIDS THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-483-2461
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:STE 280
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5938
Mailing Address - Country:US
Mailing Address - Phone:517-202-9123
Mailing Address - Fax:517-323-9531
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:STE 280
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5938
Practice Address - Country:US
Practice Address - Phone:517-202-9123
Practice Address - Fax:517-323-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088826104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty