Healthcare Provider Details

I. General information

NPI: 1891913174
Provider Name (Legal Business Name): CATHERINE ANN NIETUPSKI M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1648 11 MILE RD NE
COMSTOCK PARK MI
49321-9588
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-7775
  • Fax: 616-456-8568
Mailing address:
  • Phone: 616-866-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL980948
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: