Healthcare Provider Details

I. General information

NPI: 1104544170
Provider Name (Legal Business Name): JULIA HETTINGER LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. AXEL FRANCSICO HETTINGER

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

133 WESTOWN DR NW APT 202
GRAND RAPIDS MI
49534-3715
US

V. Phone/Fax

Practice location:
  • Phone: 207-616-2587
  • Fax:
Mailing address:
  • Phone: 919-995-2987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851115331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: