Basic Information
| Provider Information | |||||||||
| NPI: | 1326648221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMMENECKER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 454 NORWOOD AVE SE # 2 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495062711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893262679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | 6851114045 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.