Healthcare Provider Details

I. General information

NPI: 1134548951
Provider Name (Legal Business Name): CASSIE JO CLEARY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 STATE ST SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

117 PAGE ST NE
GRAND RAPIDS MI
49505-5051
US

V. Phone/Fax

Practice location:
  • Phone: 616-249-0159
  • Fax:
Mailing address:
  • Phone: 815-545-8683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097164
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.016564
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: