Healthcare Provider Details

I. General information

NPI: 1255093407
Provider Name (Legal Business Name): MRS. LENA AGNEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2566 WOODMEADOW DR SE
GRAND RAPIDS MI
49546-8031
US

IV. Provider business mailing address

3080 BAKER PARK DR SE
GRAND RAPIDS MI
49508-1417
US

V. Phone/Fax

Practice location:
  • Phone: 616-719-0194
  • Fax:
Mailing address:
  • Phone: 616-717-2580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108541
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: