MEDICARE: MRS. ANISSA LAUREN EDDIE

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	6801088649	MI

General Provider Information

NPI Number	:	1740594720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANISSA LAUREN EDDIE

Provider Business Mailing Address
First Line	:	1532 PINE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3029
Country	:	US
Telephone Number	:	616-247-3815
Fax Number	:	616-245-0450

Provider Business Practice Location Address
First Line	:	1532 PINE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3029
Country	:	US
Telephone Number	:	616-247-3815
Fax Number	:	616-245-0450

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

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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