Healthcare Provider Details

I. General information

NPI: 1336792324
Provider Name (Legal Business Name): HEATHER DUTHLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 KINNEY AVE NW
GRAND RAPIDS MI
49534
US

IV. Provider business mailing address

648 KINNEY AVE NW
GRAND RAPIDS MI
49534
US

V. Phone/Fax

Practice location:
  • Phone: 616-889-9098
  • Fax:
Mailing address:
  • Phone: 616-889-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: HEATHER E DUTHLER
Title or Position: PROVIDER
Credential: LMSW
Phone: 616-889-9098