Healthcare Provider Details

I. General information

NPI: 1073798328
Provider Name (Legal Business Name): PHILIP SCOTT SLACHTER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

805 LEONARD ST NE
GRAND RAPIDS MI
49503-1138
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax: 616-942-0589
Mailing address:
  • Phone: 616-451-2021
  • Fax: 616-451-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801066185
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: