Provider Demographics
NPI:1972560357
Name:TEADT BRINKLOW, DEBRA SUE (LMSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:TEADT BRINKLOW
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:SUE
Other - Last Name:TEADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:950 TAYLOR AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2281
Mailing Address - Country:US
Mailing Address - Phone:734-645-5684
Mailing Address - Fax:
Practice Address - Street 1:950 TAYLOR AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2281
Practice Address - Country:US
Practice Address - Phone:734-645-5684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801032927104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ44951Medicare UPIN
MIM12270051Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL