Healthcare Provider Details

I. General information

NPI: 1023164670
Provider Name (Legal Business Name): KATIE FENNELL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 DEAN LAKE AVE NE
GRAND RAPIDS MI
49505-4446
US

IV. Provider business mailing address

2340 DEAN LAKE AVE NE
GRAND RAPIDS MI
49505-4446
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-6014
  • Fax: 616-361-8051
Mailing address:
  • Phone: 616-361-6014
  • Fax: 616-361-8051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: