Provider Demographics
NPI:1255156501
Name:MIDWEST DIALECTICAL BEHAVIOR THERAPY, LLC
Entity type:Organization
Organization Name:MIDWEST DIALECTICAL BEHAVIOR THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:616-328-6109
Mailing Address - Street 1:625 KENMOOR AVE SE STE 301
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-328-6109
Mailing Address - Fax:616-328-6529
Practice Address - Street 1:2501 CHATHAM RD STE N
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:616-328-6109
Practice Address - Fax:616-328-6529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty