Provider Demographics
NPI:1841387099
Name:THIRD COAST COUNSELING CENTER
Entity Type:Organization
Organization Name:THIRD COAST COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMSW
Authorized Official - Phone:616-451-3008
Mailing Address - Street 1:1514 WEALTHY ST SE
Mailing Address - Street 2:STE 260
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2755
Mailing Address - Country:US
Mailing Address - Phone:616-451-3008
Mailing Address - Fax:616-451-3070
Practice Address - Street 1:1514 WEALTHY ST SE
Practice Address - Street 2:STE 260
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2755
Practice Address - Country:US
Practice Address - Phone:616-451-3008
Practice Address - Fax:616-451-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010358291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty