Healthcare Provider Details

I. General information

NPI: 1851050686
Provider Name (Legal Business Name): MARTHA PETTIJOHN ANDERSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 EAGLE CREST DR NE
GRAND RAPIDS MI
49525-7005
US

IV. Provider business mailing address

1087 FERNRIDGE AVE SE
GRAND RAPIDS MI
49546-3876
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-5664
  • Fax:
Mailing address:
  • Phone: 616-988-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801091266
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: