Provider Demographics
NPI:1851050686
Name:ANDERSON, MARTHA PETTIJOHN (LMSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:PETTIJOHN
Last Name:ANDERSON
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 1:1087 FERNRIDGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3876
Mailing Address - Country:US
Mailing Address - Phone:616-988-5093
Mailing Address - Fax:
Practice Address - Street 1:3215 EAGLE CREST DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7005
Practice Address - Country:US
Practice Address - Phone:616-456-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010912661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical