MEDICARE: LAVANGE BARTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1124643689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAVANGE BARTH LLC

Provider Business Mailing Address
First Line	:	848 GRACELAND ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4376
Country	:	US
Telephone Number	:	616-913-8590
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 MONROE AVE NW STE 400
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1476
Country	:	US
Telephone Number	:	616-913-8590
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAVANGE BARTH
Credential	:	LMSW
Telephone Number	:	616-913-8590

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	06/10/2020

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