Healthcare Provider Details

I. General information

NPI: 1760136659
Provider Name (Legal Business Name): LASHAWNTELLE LATRICE CARSON-POPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 FULTON ST E
GRAND RAPIDS MI
49503-3849
US

IV. Provider business mailing address

3261 COACH LN SE APT 3B
KENTWOOD MI
49512-8015
US

V. Phone/Fax

Practice location:
  • Phone: 616-742-0351
  • Fax:
Mailing address:
  • Phone: 616-262-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801110380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: