MEDICARE: MS. LISA JEAN RATHBUN L.M.S.W., A.C.S.W.

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	101YP2500X	Professional Counselor	6801078044	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6801078044	OTHER	MI	S.W. REGISTRATION

General Provider Information

NPI Number	:	1811056872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA JEAN RATHBUN L.M.S.W., A.C.S.W.

Provider Business Mailing Address
First Line	:	3130 HOEHN ST N.W.
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-2488
Country	:	US
Telephone Number	:	616-726-6437
Fax Number	:	616-957-1438

Provider Business Practice Location Address
First Line	:	4477 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3632
Country	:	US
Telephone Number	:	616-726-6437
Fax Number	:	616-957-1438

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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