Healthcare Provider Details

I. General information

NPI: 1376739771
Provider Name (Legal Business Name): LAVANGE E BARTH LMSW, CAADC, ADS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DR SE STE 101
GRAND RAPIDS MI
49546-8294
US

IV. Provider business mailing address

4070 LAKE DR SE STE 101
GRAND RAPIDS MI
49546-8294
US

V. Phone/Fax

Practice location:
  • Phone: 616-913-8590
  • Fax:
Mailing address:
  • Phone: 616-913-8590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093758
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: