Provider Demographics
NPI:1922146091
Name:DOZEMAN, REBECCA (LLMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:DOZEMAN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:DOZEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-0294
Mailing Address - Country:US
Mailing Address - Phone:616-224-7617
Mailing Address - Fax:616-224-7593
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:616-224-1617
Practice Address - Fax:616-224-7593
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010862351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483587Medicaid