Provider Demographics
NPI:1164814695
Name:BOTMA, GINETTE ANTONIA
Entity Type:Individual
Prefix:
First Name:GINETTE
Middle Name:ANTONIA
Last Name:BOTMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINETTE
Other - Middle Name:ANTONIA
Other - Last Name:JEFFERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3932 CLYDE PARK AVE SW
Mailing Address - Street 2:APT. 210
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-5437
Mailing Address - Country:US
Mailing Address - Phone:616-255-6789
Mailing Address - Fax:
Practice Address - Street 1:1939 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-2459
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010966521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical