Healthcare Provider Details

I. General information

NPI: 1982256087
Provider Name (Legal Business Name): ELIZABETH MAITNER NIELSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E BELTLINE AVE NE STE 100
GRAND RAPIDS MI
49506-1214
US

IV. Provider business mailing address

PO BOX 295
ROCKFORD MI
49341-0295
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax:
Mailing address:
  • Phone: 616-821-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801103040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: