MEDICARE: KIMBERLY WETTERMAN MSW

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	6801086339	MI

General Provider Information

NPI Number	:	1588823454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY WETTERMAN MSW

Provider Business Mailing Address
First Line	:	14998 CLEVELAND ST STE K
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-8993
Country	:	US
Telephone Number	:	616-844-2900
Fax Number	:	616-741-1300

Provider Business Practice Location Address
First Line	:	14998 CLEVELAND ST STE K
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-8993
Country	:	US
Telephone Number	:	616-844-2900
Fax Number	:	616-741-1300

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	10/13/2015

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