Healthcare Provider Details

I. General information

NPI: 1255780979
Provider Name (Legal Business Name): GAYLE WITHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 WINONA AVE NW
GRAND RAPIDS MI
49504-4740
US

IV. Provider business mailing address

558 WINONA AVE NW
GRAND RAPIDS MI
49504-4740
US

V. Phone/Fax

Practice location:
  • Phone: 616-477-3404
  • Fax:
Mailing address:
  • Phone: 616-477-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085993
License Number StateMI

VIII. Authorized Official

Name: GAYLE WITHAM
Title or Position: SOCIAL WORK
Credential: LMSW, ACM
Phone: 616-477-3404