Provider Demographics
NPI:1770649600
Name:TYNDALL, GEORGE JOHN (LMSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOHN
Last Name:TYNDALL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 CAHILL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1162
Mailing Address - Country:US
Mailing Address - Phone:616-863-9352
Mailing Address - Fax:
Practice Address - Street 1:901 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1201
Practice Address - Country:US
Practice Address - Phone:616-224-7543
Practice Address - Fax:616-224-7593
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010724961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ43738Medicare UPIN
MID16266008Medicare ID - Type Unspecified