Healthcare Provider Details

I. General information

NPI: 1710517354
Provider Name (Legal Business Name): AMY MARIE GELDERSMA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W WESTERN AVE STE 400
MUSKEGON MI
49441-1666
US

IV. Provider business mailing address

3509 MOORE RD
BAILEY MI
49303-9602
US

V. Phone/Fax

Practice location:
  • Phone: 231-728-3442
  • Fax:
Mailing address:
  • Phone: 231-728-3442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801096601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: