Provider Demographics
NPI:1245324805
Name:HAMM, MICHAEL LARRY (LMSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LARRY
Last Name:HAMM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-454-2911
Mailing Address - Fax:616-454-1126
Practice Address - Street 1:5060 CASCADE RD SE
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-454-2911
Practice Address - Fax:616-454-1126
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801058143104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR65579Medicare UPIN
MAD16222011Medicare ID - Type UnspecifiedMEDICARE