Basic Information
| Provider Information | |||||||||
| NPI: | 1710245089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRONDSMA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 138TH AVE | ||||||||
| Address2: | |||||||||
| City: | DORR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493239557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168622561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 SHELDON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6802084280 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.