Healthcare Provider Details

I. General information

NPI: 1265076798
Provider Name (Legal Business Name): ELLEN MBUNGU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

IV. Provider business mailing address

1130 BILLINGS CT SE APT 2B
GRAND RAPIDS MI
49508-7388
US

V. Phone/Fax

Practice location:
  • Phone: 616-235-7272
  • Fax:
Mailing address:
  • Phone: 920-350-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114607
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801105656
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: