Healthcare Provider Details

I. General information

NPI: 1598394702
Provider Name (Legal Business Name): MELANIE TIBBITTS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

416 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-6484
  • Fax:
Mailing address:
  • Phone: 616-202-6484
  • Fax: 616-228-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: