MEDICARE: WESTSIDE NEUROPSYCHOLOGY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1417848763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTSIDE NEUROPSYCHOLOGY, PLLC

Provider Business Mailing Address
First Line	:	5030 CORPORATE EXCHANGE BLVD SE STE 201
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5506
Country	:	US
Telephone Number	:	616-287-4164
Fax Number	:

Provider Business Practice Location Address
First Line	:	5030 CORPORATE EXCHANGE BLVD SE STE 201
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5506
Country	:	US
Telephone Number	:	616-287-4164
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL NEUROPSYCHOLOGIST/OWNER
Name	:	DR. VELISA JOHNSON
Credential	:	PHD, ABPP-CN
Telephone Number	:	616-287-4164

Provider Enumeration Date	:	07/14/2025
Last Update Date	:	07/14/2025

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