Basic Information
| Provider Information | |||||||||
| NPI: | 1568502664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENCZEK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3292 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 854 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801078171 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.