Provider Demographics
NPI:1457996845
Name:HOLDREDGE, BENJAMIN BRYAN
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:BRYAN
Last Name:HOLDREDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 RAYBROOK ST SE STE 103
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7718
Mailing Address - Country:US
Mailing Address - Phone:616-419-4791
Mailing Address - Fax:
Practice Address - Street 1:2040 RAYBROOK ST SE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7718
Practice Address - Country:US
Practice Address - Phone:616-419-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional