Healthcare Provider Details

I. General information

NPI: 1639276348
Provider Name (Legal Business Name): KATHLEEN MARY BRICKER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 E PARIS AVE SE
GRAND RAPIDS MI
49546-6139
US

IV. Provider business mailing address

PO BOX 1767
GRAND RAPIDS MI
49501-1767
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-0700
  • Fax:
Mailing address:
  • Phone: 616-235-2090
  • Fax: 616-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801065590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: