Healthcare Provider Details

I. General information

NPI: 1962462929
Provider Name (Legal Business Name): TIMOTHY G HIBMA MSW ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 EAGLE PARK DR NE STE 106
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

PO BOX 30516 DEPT 6001A
LANSING MI
48909-8016
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-8060
  • Fax: 616-942-6690
Mailing address:
  • Phone: 616-942-8060
  • Fax: 616-942-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801016841
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: