Provider Demographics
NPI:1336712561
Name:GRAND RAPIDS PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:GRAND RAPIDS PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:616-915-8153
Mailing Address - Street 1:1186 OAKBURN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3767
Mailing Address - Country:US
Mailing Address - Phone:616-915-8153
Mailing Address - Fax:
Practice Address - Street 1:4403 CASCADE RD SE STE 8
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3673
Practice Address - Country:US
Practice Address - Phone:616-915-8153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-24
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275937583OtherINDIVIDUAL