Provider Demographics
NPI:1710245089
Name:GRONDSMA, MELISSA ANN (LBSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:GRONDSMA
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9557
Mailing Address - Country:US
Mailing Address - Phone:616-862-2561
Mailing Address - Fax:
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-965-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020842801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical