Provider Demographics
NPI:1316382492
Name:HOST, ALLYSE ANN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:ALLYSE
Middle Name:ANN
Last Name:HOST
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:ALLYSE
Other - Middle Name:ANN
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:3250 36TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-8193
Mailing Address - Country:US
Mailing Address - Phone:269-779-9587
Mailing Address - Fax:
Practice Address - Street 1:3250 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-8193
Practice Address - Country:US
Practice Address - Phone:269-779-9587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0157441101YM0800X
MI6401014454101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health