Healthcare Provider Details

I. General information

NPI: 1700272747
Provider Name (Legal Business Name): PATRICIA DIEKEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA CARLTON

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507-2459
US

IV. Provider business mailing address

1939 DIVISION AVE S
GRAND RAPIDS MI
49507-2459
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 TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096439
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: