Healthcare Provider Details

I. General information

NPI: 1720666092
Provider Name (Legal Business Name): ELSA LOCKMAN LMSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 MASON LAKE RD NE
GRAND RAPIDS MI
49525-9702
US

IV. Provider business mailing address

3551 MASON LAKE RD NE
GRAND RAPIDS MI
49525-9702
US

V. Phone/Fax

Practice location:
  • Phone: 616-915-8324
  • Fax:
Mailing address:
  • Phone: 616-915-8324
  • 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: ELSA LOCKMAN
Title or Position: OWNER
Credential:
Phone: 616-915-8324