Provider Demographics
NPI:1639358286
Name:ANDERSON, RICHARD GREGORY (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GREGORY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5938
Mailing Address - Country:US
Mailing Address - Phone:616-975-0400
Mailing Address - Fax:616-975-0474
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:SUITE 120
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5938
Practice Address - Country:US
Practice Address - Phone:616-975-0400
Practice Address - Fax:616-975-0474
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010629161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOMO2440Medicare PIN