Healthcare Provider Details

I. General information

NPI: 1417343146
Provider Name (Legal Business Name): SHEA WALLUS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 MONROE AVE NW STE 120
GRAND RAPIDS MI
49505-4678
US

IV. Provider business mailing address

PO BOX 776974
CHICAGO IL
60677-6974
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3330
  • Fax: 616-685-8915
Mailing address:
  • Phone: 800-494-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092529
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: