=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871962605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA WALCOTT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2015
-----------------------------------------------------
Last Update Date | 03/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1346 BALDWIN ST #13
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49505-5904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 167-658-5856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 218 E 1ST AVE STE C
-----------------------------------------------------
City | MITCHELL
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57301-3467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-626-1112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801115159
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------