Provider Demographics
NPI:1295972297
Name:FAISON, MARIA (LLP)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:FAISON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:MAGDALENO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLP
Mailing Address - Street 1:1115 BALL AVE. NE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505
Mailing Address - Country:US
Mailing Address - Phone:616-459-7215
Mailing Address - Fax:616-451-0020
Practice Address - Street 1:2615 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1654
Practice Address - Country:US
Practice Address - Phone:269-343-1651
Practice Address - Fax:269-382-7078
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013928103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist