Provider Demographics
NPI:1013294628
Name:139 EDUCATION, LLC.
Entity Type:Organization
Organization Name:139 EDUCATION, LLC.
Other - Org Name:NEUROCORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYER
Authorized Official - Suffix:
Authorized Official - Credentials:PSY
Authorized Official - Phone:800-600-4096
Mailing Address - Street 1:201 MONROE AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:800-600-4096
Mailing Address - Fax:800-606-8839
Practice Address - Street 1:3148 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:800-600-4096
Practice Address - Fax:800-606-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009353103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D14689OtherBLUE CROSS BLUE SHIELD OF MICHIGAN