Healthcare Provider Details

I. General information

NPI: 1295130060
Provider Name (Legal Business Name): KRISTIN POUNDERS LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

4796 18TH ST SW
BYRON CENTER MI
49315-9104
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax:
Mailing address:
  • Phone: 810-730-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802088217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: