Healthcare Provider Details

I. General information

NPI: 1295495380
Provider Name (Legal Business Name): ANDREW EUGENE EASTHAM LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ECKLUND ST NE
GRAND RAPIDS MI
49505-4324
US

IV. Provider business mailing address

1108 ECKLUND ST NE
GRAND RAPIDS MI
49505-4324
US

V. Phone/Fax

Practice location:
  • Phone: 616-970-9536
  • Fax:
Mailing address:
  • Phone: 616-970-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801081217
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801081217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: