Provider Demographics
NPI:1740594720
Name:EDDIE, ANISSA LAUREN
Entity Type:Individual
Prefix:MRS
First Name:ANISSA
Middle Name:LAUREN
Last Name:EDDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANISSA
Other - Middle Name:LAUREN
Other - Last Name:ADKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1532 PINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3029
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:1532 PINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3029
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:616-245-0450
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010886491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical