Provider Demographics
NPI:1255541462
Name:LIST, ANNITA (LMSW)
Entity type:Individual
Prefix:
First Name:ANNITA
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 CLAUDIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49548-5844
Mailing Address - Country:US
Mailing Address - Phone:616-531-5315
Mailing Address - Fax:616-451-1965
Practice Address - Street 1:744 BURTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3204
Practice Address - Country:US
Practice Address - Phone:616-451-1965
Practice Address - Fax:616-451-2012
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010613251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7000013901Medicaid
MII01OtherNETWORK180