Healthcare Provider Details

I. General information

NPI: 1265188965
Provider Name (Legal Business Name): STACIE RUBLEIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 EASTMOOR AVE SE
GRAND RAPIDS MI
49546-2274
US

IV. Provider business mailing address

371 EASTMOOR AVE SE
GRAND RAPIDS MI
49546-2274
US

V. Phone/Fax

Practice location:
  • Phone: 616-295-0756
  • Fax:
Mailing address:
  • Phone: 616-295-0756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085186
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: