Provider Demographics
NPI:1568866754
Name:FOUNTAIN HILL CENTER -- LAKESHORE OFFICE
Entity Type:Organization
Organization Name:FOUNTAIN HILL CENTER -- LAKESHORE OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN GUNST
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:616-456-1178
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:NEW ERA
Mailing Address - State:MI
Mailing Address - Zip Code:49446-0032
Mailing Address - Country:US
Mailing Address - Phone:616-456-1178
Mailing Address - Fax:
Practice Address - Street 1:534 FOUNTAIN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3422
Practice Address - Country:US
Practice Address - Phone:616-456-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNTAIN HILL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health