Healthcare Provider Details

I. General information

NPI: 1417544487
Provider Name (Legal Business Name): ASHLYNN LISTER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2020
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 PENINSULAR DR SE STE 230
GRAND RAPIDS MI
49546-6187
US

IV. Provider business mailing address

3940 PENINSULAR DR SE STE 230
GRAND RAPIDS MI
49546-6187
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-0692
  • Fax: 616-458-8129
Mailing address:
  • Phone: 616-458-0692
  • Fax: 616-458-8129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109095
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: