Healthcare Provider Details

I. General information

NPI: 1225639560
Provider Name (Legal Business Name): ANANYA AVINASH LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 60TH ST SE
GRAND RAPIDS MI
49508-7065
US

IV. Provider business mailing address

1403 60TH ST SE
GRAND RAPIDS MI
49508-7065
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax: 616-805-3631
Mailing address:
  • Phone: 616-805-3660
  • Fax: 616-805-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801104718
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: