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General NPI Number Information
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NPI Number | 1609017821
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Entity Type | Individual
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Provider Name | RICHARD BRUCE EISEN LMSW
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Gender | Male
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Dates
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Enumeration Date | 03/18/2009
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Last Update Date | 03/18/2009
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Provider Practice Location Address
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Address Line | 1492 E BELTLINE AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-4336
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Country | US
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Telephone | 616-464-0294
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Fax | 616-940-1055
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Provider Business Mailing Address
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Address Line | 1492 E BELTLINE AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-4336
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Country | US
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Telephone | 616-464-0294
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Fax | 616-940-1055
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801021183
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License Number State | MI
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