Provider Demographics
NPI:1659121507
Name:HENDRICKS, MICHAEL (CHW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:ASH
Other - Middle Name:
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:669 STOCKING AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5176
Mailing Address - Country:US
Mailing Address - Phone:616-235-1480
Mailing Address - Fax:
Practice Address - Street 1:669 STOCKING AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5176
Practice Address - Country:US
Practice Address - Phone:616-235-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker