Provider Demographics
NPI:1669037685
Name:DISCLOSURES LLC
Entity Type:Organization
Organization Name:DISCLOSURES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-634-3301
Mailing Address - Street 1:2017 COLLEGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3101
Mailing Address - Country:US
Mailing Address - Phone:616-634-3301
Mailing Address - Fax:616-333-7747
Practice Address - Street 1:2017 COLLEGE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3101
Practice Address - Country:US
Practice Address - Phone:616-634-3301
Practice Address - Fax:616-333-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8611393Medicaid
MI0965761OtherBCBSM