Healthcare Provider Details

I. General information

NPI: 1447796958
Provider Name (Legal Business Name): EILEEN CHAMBERLIN LMSW, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 EAGLE RUN DR NE STE 200
GRAND RAPIDS MI
49525-7051
US

IV. Provider business mailing address

3210 EAGLE RUN DR NE STE 200
GRAND RAPIDS MI
49525-7051
US

V. Phone/Fax

Practice location:
  • Phone: 616-279-3725
  • Fax: 616-279-3723
Mailing address:
  • Phone: 616-279-3725
  • Fax: 616-279-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801095461
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number6801095461
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095461
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: