Provider Demographics
NPI:1134016785
Name:COLLINS, BENJAMIN DAVID (LLC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DAVID
Last Name:COLLINS
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 BRIDGEPORT RD NE APT 121
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6308
Mailing Address - Country:US
Mailing Address - Phone:708-949-1628
Mailing Address - Fax:
Practice Address - Street 1:1750 GRAND RIDGE CT NE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7043
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:616-404-4103
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health