Provider Demographics
NPI:1790420990
Name:GRAND RAPIDS INTEGRATIVE THERAPY
Entity Type:Organization
Organization Name:GRAND RAPIDS INTEGRATIVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-889-6602
Mailing Address - Street 1:4120 CHICAGO DR SW STE 1
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1281
Mailing Address - Country:US
Mailing Address - Phone:616-889-6602
Mailing Address - Fax:
Practice Address - Street 1:4120 CHICAGO DR SW STE 1
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1281
Practice Address - Country:US
Practice Address - Phone:616-889-6602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty