Provider Demographics
NPI:1487691358
Name:BAZAN, CRISELDA (LMSW)
Entity type:Individual
Prefix:
First Name:CRISELDA
Middle Name:
Last Name:BAZAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 HOOVER BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3755
Mailing Address - Country:US
Mailing Address - Phone:616-591-9400
Mailing Address - Fax:616-591-9060
Practice Address - Street 1:238 HOOVER BLVD STE 10
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3755
Practice Address - Country:US
Practice Address - Phone:616-591-9400
Practice Address - Fax:616-591-9060
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010798591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF16408030Medicare ID - Type Unspecified
MI1712452Medicare PIN