Provider Demographics
NPI:1225174709
Name:WADDILOVE, ESTHER (LMSW)
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:
Last Name:WADDILOVE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 202-A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8621
Mailing Address - Country:US
Mailing Address - Phone:616-222-3090
Mailing Address - Fax:616-957-1438
Practice Address - Street 1:770 KENMOOR AVE SE
Practice Address - Street 2:SUITE 202-A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8621
Practice Address - Country:US
Practice Address - Phone:616-222-3090
Practice Address - Fax:616-957-1438
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010628841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM60790Medicare ID - Type Unspecified