Healthcare Provider Details

I. General information

NPI: 1316962905
Provider Name (Legal Business Name): CLARICE DAWN KWANT M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 COIT AVE NE
GRAND RAPIDS MI
49505-3376
US

IV. Provider business mailing address

4483 8TH AVE SW
GRANDVILLE MI
49418-9698
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9575
  • Fax: 616-365-9480
Mailing address:
  • Phone: 616-365-9575
  • Fax: 616-365-9480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801033250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: