Provider Demographics
NPI:1407233851
Name:FENNEMA, MEREDITH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:FENNEMA
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 1:201 MONROE AVE NW
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2212
Mailing Address - Country:US
Mailing Address - Phone:800-600-4096
Mailing Address - Fax:800-606-8839
Practice Address - Street 1:201 MONROE AVE NW
Practice Address - Street 2:SUITE 400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2212
Practice Address - Country:US
Practice Address - Phone:800-600-4096
Practice Address - Fax:800-606-8839
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093653104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker