MEDICARE: ANANYA AVINASH LMSW

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	6801104718	MI

General Provider Information

NPI Number	:	1225639560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANANYA AVINASH LMSW

Provider Business Mailing Address
First Line	:	1403 60TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7065
Country	:	US
Telephone Number	:	616-805-3660
Fax Number	:	616-805-3631

Provider Business Practice Location Address
First Line	:	1403 60TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7065
Country	:	US
Telephone Number	:	616-805-3660
Fax Number	:	616-805-3631

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

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	12/08/2020

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