Provider Demographics
NPI:1922309947
Name:DENDRINOS, ALYSIA MARIE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:ALYSIA
Middle Name:MARIE
Last Name:DENDRINOS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:ALYSIA
Other - Middle Name:MARIE
Other - Last Name:NAWROCKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:201 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4513
Mailing Address - Country:US
Mailing Address - Phone:616-459-0255
Mailing Address - Fax:
Practice Address - Street 1:360 E BELTLINE AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1214
Practice Address - Country:US
Practice Address - Phone:616-566-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010901911041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38 2831313OtherTAX ID
MI0D16159Medicare PIN