Provider Demographics
NPI:1861701229
Name:D.A. BLODGETT - ST. JOHN'S
Entity type:Organization
Organization Name:D.A. BLODGETT - ST. JOHN'S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:KSSN SITE TEAM CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JON
Authorized Official - Last Name:BROWER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LMSW
Authorized Official - Phone:616-826-6063
Mailing Address - Street 1:805 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1138
Practice Address - Country:US
Practice Address - Phone:616-451-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088412251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health