Healthcare Provider Details

I. General information

NPI: 1366811549
Provider Name (Legal Business Name): SUSAN MONTROY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-1991
  • Fax:
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068059
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: