Healthcare Provider Details

I. General information

NPI: 1538725213
Provider Name (Legal Business Name): ENEMECIA K ESCALANTE BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3024 WOODBRIDGE DR SE APT 203
KENTWOOD MI
49512-1967
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax:
Mailing address:
  • Phone: 616-375-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: