Healthcare Provider Details

I. General information

NPI: 1194056457
Provider Name (Legal Business Name): TIMOTHY GERARD LEONARD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 3 MILE RD NW STE 150
GRAND RAPIDS MI
49544-8218
US

IV. Provider business mailing address

1148 ORCHARD AVE SE
GRAND RAPIDS MI
49506-3547
US

V. Phone/Fax

Practice location:
  • Phone: 616-647-3460
  • Fax:
Mailing address:
  • Phone: 616-855-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6801082003
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: