Healthcare Provider Details

I. General information

NPI: 1104330307
Provider Name (Legal Business Name): GAYLE WITHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 WINONA AVE NW
GRAND RAPIDS MI
49504-4740
US

IV. Provider business mailing address

558 WINONA AVE NW
GRAND RAPIDS MI
49504-4740
US

V. Phone/Fax

Practice location:
  • Phone: 616-477-3404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: