Healthcare Provider Details

I. General information

NPI: 1306207881
Provider Name (Legal Business Name): REBECCA MCDANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PEARL ST NW STE 341
GRAND RAPIDS MI
49503-3026
US

IV. Provider business mailing address

309 WOODMERE AVE SE
GRAND RAPIDS MI
49506-1724
US

V. Phone/Fax

Practice location:
  • Phone: 708-420-4989
  • Fax:
Mailing address:
  • Phone: 708-420-4989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149018251
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC012553
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: