Healthcare Provider Details

I. General information

NPI: 1497227292
Provider Name (Legal Business Name): CARLOS DEL VALLE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CORPORATE EXCHANGE BLVD SE FL 2
GRAND RAPIDS MI
49512-5506
US

IV. Provider business mailing address

6722 34TH AVE
HUDSONVILLE MI
49426-9093
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-8202
  • Fax:
Mailing address:
  • Phone: 616-885-8202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801116834
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: