Provider Demographics
NPI:1013952167
Name:MEUZELAAR, CALVIN MARK (LISW, LMSW)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:MARK
Last Name:MEUZELAAR
Suffix:
Gender:M
Credentials:LISW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5270
Mailing Address - Fax:616-455-5460
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5270
Practice Address - Fax:616-455-5460
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00572104100000X
MI68010197861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0136234Medicaid
IA04383Medicare ID - Type Unspecified
IA0136234Medicaid