Healthcare Provider Details

I. General information

NPI: 1700284130
Provider Name (Legal Business Name): BENJAMIN GITLER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 06/07/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONROE AVE NW STE 202
GRAND RAPIDS MI
49503-1448
US

IV. Provider business mailing address

2177 WOODLARK DR
HOLLAND MI
49424-2800
US

V. Phone/Fax

Practice location:
  • Phone: 616-239-2566
  • Fax:
Mailing address:
  • Phone: 616-283-8619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088730
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: