Basic Information
| Provider Information | |||||||||
| NPI: | 1821502436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEEDORF | ||||||||
| FirstName: | GLADYS | ||||||||
| MiddleName: | JEWEL | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11135 BURROWS RD | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490148193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699866372 | ||||||||
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| Practice Location | |||||||||
| Address1: | 370 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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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 | 6801086469 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6801086469 | 01 | MI | STATE LICENSE | OTHER |