Provider Demographics
NPI:1073722542
Name:CHILD, MARY BETH (LLP)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:CHILD
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 PLAINFIELD AVE NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1644
Mailing Address - Country:US
Mailing Address - Phone:616-361-3398
Mailing Address - Fax:616-361-3395
Practice Address - Street 1:4701 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1644
Practice Address - Country:US
Practice Address - Phone:616-361-3398
Practice Address - Fax:616-361-3395
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010573103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral