Provider Demographics
NPI:1407252232
Name:VR THERAPY AND COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:VR THERAPY AND COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:OVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-988-9049
Mailing Address - Street 1:1618 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6438
Mailing Address - Country:US
Mailing Address - Phone:616-988-9049
Mailing Address - Fax:
Practice Address - Street 1:1618 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6438
Practice Address - Country:US
Practice Address - Phone:616-988-9049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2607651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty