Provider Demographics
NPI:1639418288
Name:GENZINK, MELISTA DEE (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISTA
Middle Name:DEE
Last Name:GENZINK
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 1:516 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4702
Mailing Address - Country:US
Mailing Address - Phone:616-456-6135
Mailing Address - Fax:616-771-9779
Practice Address - Street 1:516 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4702
Practice Address - Country:US
Practice Address - Phone:616-456-6135
Practice Address - Fax:616-771-9779
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
MI68010918361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator