Healthcare Provider Details

I. General information

NPI: 1649329640
Provider Name (Legal Business Name): MARYBETH ATWELL L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE STE 104C
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

4572 S HAGADORN RD SUITE 2B
EAST LANSING MI
48823-5385
US

V. Phone/Fax

Practice location:
  • Phone: 517-333-3950
  • Fax:
Mailing address:
  • Phone: 517-333-3950
  • Fax: 517-333-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801033562
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: