Healthcare Provider Details

I. General information

NPI: 1578288510
Provider Name (Legal Business Name): TIMOTHY ROBERT NOVAK LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKE DR SE STE 8
GRAND RAPIDS MI
49506-1673
US

IV. Provider business mailing address

335 MADISON AVE SE APT 2
GRAND RAPIDS MI
49503-4617
US

V. Phone/Fax

Practice location:
  • Phone: 616-901-9549
  • Fax:
Mailing address:
  • Phone: 616-901-9549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801107413
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: