Healthcare Provider Details

I. General information

NPI: 1689417909
Provider Name (Legal Business Name): DAWN WALCOTT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RAYBROOK ST SE
GRAND RAPIDS MI
49546-7718
US

IV. Provider business mailing address

510 EDWARD ST
MIDDLEVILLE MI
49333-9775
US

V. Phone/Fax

Practice location:
  • Phone: 616-818-5911
  • Fax:
Mailing address:
  • Phone: 616-818-5911
  • 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: DAWN RENEE WALCOTT
Title or Position: CEO
Credential: LMSW
Phone: 616-818-5911