Provider Demographics
NPI:1255093407
Name:AGNEW, LENA
Entity Type:Individual
Prefix:MRS
First Name:LENA
Middle Name:
Last Name:AGNEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 BAKER PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1417
Mailing Address - Country:US
Mailing Address - Phone:616-717-2580
Mailing Address - Fax:
Practice Address - Street 1:2566 WOODMEADOW DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8031
Practice Address - Country:US
Practice Address - Phone:616-719-0194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011085411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical