Healthcare Provider Details

I. General information

NPI: 1831746254
Provider Name (Legal Business Name): STEVEN JAMES BRISTOL LMSW, MDIV, CAADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 FULTON ST W
GRAND RAPIDS MI
49504-6404
US

IV. Provider business mailing address

205 ROSEBUD LN SW
WALKER MI
49534-5872
US

V. Phone/Fax

Practice location:
  • Phone: 616-780-5402
  • Fax: 616-222-0631
Mailing address:
  • Phone: 616-780-0542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801113916
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: