Healthcare Provider Details

I. General information

NPI: 1093215485
Provider Name (Legal Business Name): DANIEL SLANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
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

1243 CALVIN AVE SE
GRAND RAPIDS MI
49506-3209
US

V. Phone/Fax

Practice location:
  • Phone: 616-706-5084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801102247
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: