Healthcare Provider Details

I. General information

NPI: 1790095834
Provider Name (Legal Business Name): ELIZABETH GARDNER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E BELTLINE AVE SE STE 255
GRAND RAPIDS MI
49506-4362
US

IV. Provider business mailing address

2181 ENGLESIDE DR SE
GRAND RAPIDS MI
49546-6224
US

V. Phone/Fax

Practice location:
  • Phone: 616-947-4440
  • Fax:
Mailing address:
  • Phone: 616-240-6668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801090857
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: