Provider Demographics
NPI:1255780979
Name:GAYLE WITHAM
Entity type:Organization
Organization Name:GAYLE WITHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORK
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, ACM
Authorized Official - Phone:616-477-3404
Mailing Address - Street 1:558 WINONA AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4740
Mailing Address - Country:US
Mailing Address - Phone:616-477-3404
Mailing Address - Fax:
Practice Address - Street 1:558 WINONA AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4740
Practice Address - Country:US
Practice Address - Phone:616-477-3404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010859931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty