Healthcare Provider Details

I. General information

NPI: 1114335817
Provider Name (Legal Business Name): MARY ALICE WALKER BLANKER LMSW, CAADC, ADS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ALICE WALKER LMSW, CAADC, ADS

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE, NE BUILDING C
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1115 BALL AVE, NE BUILDING C
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7215
  • Fax: 616-451-0020
Mailing address:
  • Phone: 616-459-7215
  • Fax: 616-451-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093780
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: