Provider Demographics
NPI:1689039851
Name:MCMAHON, MICHELLE ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-8614
Practice Address - Country:US
Practice Address - Phone:616-447-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096348104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker