Provider Demographics
NPI:1679899280
Name:GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC
Entity Type:Organization
Organization Name:GRAND RAPIDS CENTER FOR PSYCHOTHERAPY PLLC
Other - Org Name:CAROLYN H. CARINO LMSW ACSW SPADA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CARINO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW ACSW SPADA
Authorized Official - Phone:616-949-6262
Mailing Address - Street 1:4519 CASCADE RD SE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3666
Mailing Address - Country:US
Mailing Address - Phone:616-949-6262
Mailing Address - Fax:616-425-2003
Practice Address - Street 1:4519 CASCADE RD SE
Practice Address - Street 2:SUITE 3
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3666
Practice Address - Country:US
Practice Address - Phone:616-949-6262
Practice Address - Fax:616-425-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680103034469251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801034469OtherSTATE OF MICHIGAN DEPARTMENT OF COMMUNITY HEALTH LICENSE
881817049OtherNATIONAL ASSOCIATION OF SOCIAL WORKERS ACADEMY OF CERTIFIED SOCIAL WORKERS