Healthcare Provider Details

I. General information

NPI: 1336899426
Provider Name (Legal Business Name): ELIZABETH JANE VALLIER-BOOTH LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH JANE VALLIER LLMSW

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 COLLEGE AVE SE
GRAND RAPIDS MI
49503-5921
US

IV. Provider business mailing address

PO BOX 944
ADA MI
49301-0944
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-4815
  • Fax:
Mailing address:
  • Phone: 616-550-8537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851099325
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: