Healthcare Provider Details

I. General information

NPI: 1710245089
Provider Name (Legal Business Name): MELISSA ANN GRONDSMA LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

IV. Provider business mailing address

1921 138TH AVE
DORR MI
49323-9557
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone: 616-862-2561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802084280
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: