Healthcare Provider Details

I. General information

NPI: 1497366967
Provider Name (Legal Business Name): KRISTA L. LEINBERGER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 FAIRVIEW AVE NE APT 1
GRAND RAPIDS MI
49503-2581
US

IV. Provider business mailing address

PO BOX 1626
GRAND RAPIDS MI
49501-1626
US

V. Phone/Fax

Practice location:
  • Phone: 616-710-1379
  • Fax:
Mailing address:
  • Phone: 616-710-1379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KRISTA LYNN LIST-LEINBERGER
Title or Position: PRESIDENT/THERAPIST
Credential: LMSW
Phone: 616-710-1379