Provider Demographics
NPI:1386378610
Name:HOUSE, HEATHER JUSTINE (LLMSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:JUSTINE
Last Name:HOUSE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5049 HARBOR HOUSE LN APT 301
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-7317
Mailing Address - Country:US
Mailing Address - Phone:616-644-5036
Mailing Address - Fax:
Practice Address - Street 1:1428 44TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4312
Practice Address - Country:US
Practice Address - Phone:616-279-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511153691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical