Healthcare Provider Details

I. General information

NPI: 1639291396
Provider Name (Legal Business Name): TENDAI MASIRIRI LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 LAKE DR SE
GRAND RAPIDS MI
49506-1674
US

IV. Provider business mailing address

2943 WINGATE DR SE
KENTWOOD MI
49512-8096
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7215
  • Fax:
Mailing address:
  • Phone: 616-975-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: