Provider Demographics
NPI:1376261065
Name:LITWIN, HAILEY L
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:L
Last Name:LITWIN
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 1:4873 BURRWOOD ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3769
Mailing Address - Country:US
Mailing Address - Phone:616-900-5001
Mailing Address - Fax:
Practice Address - Street 1:4873 BURRWOOD ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3769
Practice Address - Country:US
Practice Address - Phone:616-900-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI87-0929461Medicaid