Provider Demographics
NPI:1245303809
Name:CATHOLIC CHARITIES WEST MICHIGAN
Entity type:Organization
Organization Name:CATHOLIC CHARITIES WEST MICHIGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:NYKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, ACSW, LMSW
Authorized Official - Phone:616-243-9122
Mailing Address - Street 1:40 JEFFERSON
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-456-1443
Mailing Address - Fax:616-732-6392
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-356-6216
Practice Address - Fax:616-732-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245303809Medicaid
MI7509106890Medicare UPIN
MI750910530Medicare UPIN
MI0N62400Medicare PIN