Healthcare Provider Details

I. General information

NPI: 1891079398
Provider Name (Legal Business Name): TERI A MARIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 NORTHLAND DR NE SUITE A
GRAND RAPIDS MI
49525-1096
US

IV. Provider business mailing address

5250 NORTHLAND DR NE SUITE A
GRAND RAPIDS MI
49525-1096
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-5001
  • Fax: 616-361-2166
Mailing address:
  • Phone: 616-361-5001
  • Fax: 616-361-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085769
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: