Provider Demographics
NPI:1801014220
Name:CLODFELDER MOOREHEAD, REBECCA MAE (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAE
Last Name:CLODFELDER MOOREHEAD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5758 E GROVE DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9524
Mailing Address - Country:US
Mailing Address - Phone:616-698-6762
Mailing Address - Fax:
Practice Address - Street 1:1331 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:616-459-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010768701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical