Healthcare Provider Details

I. General information

NPI: 1225174709
Provider Name (Legal Business Name): ESTHER WADDILOVE L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE SUITE 202-A
GRAND RAPIDS MI
49546-8621
US

IV. Provider business mailing address

770 KENMOOR AVE SE SUITE 202-A
GRAND RAPIDS MI
49546-8621
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-3090
  • Fax: 616-957-1438
Mailing address:
  • Phone: 616-222-3090
  • Fax: 616-957-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801062884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: