Healthcare Provider Details

I. General information

NPI: 1447878004
Provider Name (Legal Business Name): SILVIA CRISTINA DYSON LMSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6105 WILSON AVE SW STE 202
WYOMING MI
49418-9714
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-5299
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number68010194945
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: