MEDICARE: KEN TABER MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801066952	MI

General Provider Information

NPI Number	:	1154615789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEN TABER MSW

Provider Business Mailing Address
First Line	:	1345 MONROE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4671
Country	:	US
Telephone Number	:	616-233-1187
Fax Number	:

Provider Business Practice Location Address
First Line	:	1345 MONROE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-4671
Country	:	US
Telephone Number	:	616-233-1187
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	05/31/2011

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Directions to “ KEN TABER MSW” Practice Location

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