Provider Demographics
NPI:1710031133
Name:SQUIRES, HENRIETTA NMN (MSW, OTR)
Entity Type:Individual
Prefix:MRS
First Name:HENRIETTA
Middle Name:NMN
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:MSW, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 36TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2319
Mailing Address - Country:US
Mailing Address - Phone:616-248-5112
Mailing Address - Fax:616-243-2302
Practice Address - Street 1:781 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2319
Practice Address - Country:US
Practice Address - Phone:616-248-5112
Practice Address - Fax:616-243-2302
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802058948104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker