Healthcare Provider Details

I. General information

NPI: 1477069813
Provider Name (Legal Business Name): LISA SUZANNE MEENGS LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-258-7543
  • Fax: 616-389-1069
Mailing address:
  • Phone: 616-258-7543
  • Fax: 616-389-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801101389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: