Provider Demographics
NPI:1366701781
Name:MASTERTON, THEODORE WILLIAM (LMSW)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:MASTERTON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 BALSAM AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2885
Mailing Address - Country:US
Mailing Address - Phone:616-365-8582
Mailing Address - Fax:
Practice Address - Street 1:3338 BALSAM AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2885
Practice Address - Country:US
Practice Address - Phone:616-365-8582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010181391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical