Provider Demographics
NPI:1922188028
Name:MUDDE, DIANA GRACE (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:GRACE
Last Name:MUDDE
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WIERSMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, ACSW
Mailing Address - Street 1:36 W 8TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2708
Mailing Address - Country:US
Mailing Address - Phone:616-796-6635
Mailing Address - Fax:
Practice Address - Street 1:36 W 8TH ST STE 250
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2708
Practice Address - Country:US
Practice Address - Phone:616-796-6635
Practice Address - Fax:888-237-4235
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010867861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical