Healthcare Provider Details

I. General information

NPI: 1609017821
Provider Name (Legal Business Name): RICHARD BRUCE EISEN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

1492 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

V. Phone/Fax

Practice location:
  • Phone: 616-464-0294
  • Fax: 616-940-1055
Mailing address:
  • Phone: 616-464-0294
  • Fax: 616-940-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801021183
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: