Healthcare Provider Details

I. General information

NPI: 1174962617
Provider Name (Legal Business Name): STACY LYN BLACKWELL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 FRONT AVE NW
GRAND RAPIDS MI
49504-5325
US

IV. Provider business mailing address

3122 CLYDE PARK AVE SW
WYOMING MI
49509-2918
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-3711
  • Fax: 616-825-6015
Mailing address:
  • Phone: 989-802-9583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095510
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: