Healthcare Provider Details

I. General information

NPI: 1932789286
Provider Name (Legal Business Name): EZRA ODIOKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 01/15/2025
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507
US

IV. Provider business mailing address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507
US

V. Phone/Fax

Practice location:
  • Phone: 616-247-3815
  • Fax: 616-245-0450
Mailing address:
  • Phone: 616-247-3815
  • Fax: 616-245-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851108588
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: