Provider Demographics
NPI:1750690368
Name:FORTUNA, EMILY (MA, LPC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NEGAUNEE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5321
Mailing Address - Country:US
Mailing Address - Phone:206-696-8765
Mailing Address - Fax:
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE STE 120
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5939
Practice Address - Country:US
Practice Address - Phone:206-696-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016255101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional