Healthcare Provider Details

I. General information

NPI: 1528200839
Provider Name (Legal Business Name): HEIDI JO GLEW LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6190 W. CENTERLINE RD
ST. JOHNS MI
48879
US

IV. Provider business mailing address

6190 W. CENTERLINE RD
ST. JOHNS MI
48879
US

V. Phone/Fax

Practice location:
  • Phone: 517-290-5648
  • Fax:
Mailing address:
  • Phone: 517-290-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: