Provider Demographics
NPI:1568497915
Name:PITTMAN-PARKS, GLENDA (MSW)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:PITTMAN-PARKS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MONROE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3397
Mailing Address - Country:US
Mailing Address - Phone:616-364-5295
Mailing Address - Fax:616-365-3804
Practice Address - Street 1:3000 MONROE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3397
Practice Address - Country:US
Practice Address - Phone:616-364-5295
Practice Address - Fax:616-365-3804
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010638731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIGP063873OtherBCBS OF MICHIGAN