Healthcare Provider Details

I. General information

NPI: 1003509308
Provider Name (Legal Business Name): REBECCA JOY BACK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS REBECCA JOY YOUDELL

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

2520 POWERS AVE NW
GRAND RAPIDS MI
49544-1866
US

V. Phone/Fax

Practice location:
  • Phone: 269-929-7342
  • Fax:
Mailing address:
  • Phone: 269-929-7342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801116334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: