Provider Demographics
NPI:1326108762
Name:SJOBLOM, CORRIE A (LMSW)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:A
Last Name:SJOBLOM
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 1:901 EASTERN AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1201
Mailing Address - Country:US
Mailing Address - Phone:616-965-8004
Mailing Address - Fax:
Practice Address - Street 1:1095 3RD ST
Practice Address - Street 2:SUITE125
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1976
Practice Address - Country:US
Practice Address - Phone:231-726-4735
Practice Address - Fax:231-722-0789
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010953061041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1712452Medicaid
MI750910910Medicare UPIN
MI750910903Medicare UPIN
MI1712452Medicaid
MI20378Medicare UPIN
MI750910482Medicare UPIN
MI20351Medicare UPIN
MI20366Medicare UPIN
MI20386Medicare UPIN
MI750910904Medicare UPIN
MI750910902Medicare UPIN