Healthcare Provider Details

I. General information

NPI: 1134820590
Provider Name (Legal Business Name): PERI MEY SHOEMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 5 MILE RD NE STE 101
GRAND RAPIDS MI
49525-6518
US

IV. Provider business mailing address

2730 5 MILE RD NE STE 101
GRAND RAPIDS MI
49525-6518
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-9401
  • Fax: 616-333-4303
Mailing address:
  • Phone: 616-426-9401
  • Fax: 616-333-4303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115279
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: