Healthcare Provider Details

I. General information

NPI: 1811056872
Provider Name (Legal Business Name): LISA JEAN RATHBUN L.M.S.W., A.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4477 CASCADE RD SE
GRAND RAPIDS MI
49546-3632
US

IV. Provider business mailing address

3130 HOEHN ST N.W.
GRAND RAPIDS MI
49504-2488
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-6437
  • Fax: 616-957-1438
Mailing address:
  • Phone: 616-726-6437
  • Fax: 616-957-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6801078044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: