MEDICARE: WILLIAM J. WEITZEL 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	6801011410	MI

General Provider Information

NPI Number	:	1497012975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM J. WEITZEL LMSW

Provider Business Mailing Address
First Line	:	3396 HIDDEN HILLS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-9125
Country	:	US
Telephone Number	:	616-446-1873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4467 CASCADE RD SE
Second Line	:	SUITE 4469
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3776
Country	:	US
Telephone Number	:	616-446-1873
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WILLIAM JAMES WEITZEL
Credential	:	LMSW
Telephone Number	:	616-446-1873

Provider Enumeration Date	:	04/20/2012
Last Update Date	:	04/20/2012

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