Provider Demographics
NPI:1306207881
Name:MCDANIEL, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WOODMERE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1724
Mailing Address - Country:US
Mailing Address - Phone:708-420-4989
Mailing Address - Fax:
Practice Address - Street 1:40 PEARL ST NW STE 341
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3026
Practice Address - Country:US
Practice Address - Phone:708-420-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490182511041C0700X
NCC0125531041C0700X
MI68011148591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical