MEDICARE: RENEE L VANDER MYDE MA, LLP

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	103TA0700X	Adult Development & Aging Psychologist
2	103TB0200X	Cognitive & Behavioral Psychologist	6301011876	MI
3	103TC0700X	Clinical Psychologist	6301011876	MI
4	103TC2200X	Clinical Child & Adolescent Psychologist
5	103TC2200X	Clinical Child & Adolescent Psychologist	6301011876	MI
6	103TF0000X	Family Psychologist
7	103TP2701X	Group Psychotherapy Psychologist	6301011876	MI
8	106H00000X	Marriage & Family Therapist	6301011876	MI
9	103T00000X	Psychologist	6301011876	MI

General Provider Information

NPI Number	:	1841487394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE L VANDER MYDE MA, LLP

Provider Business Mailing Address
First Line	:	1444 MICHIGAN ST NE STE 8
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2028
Country	:	US
Telephone Number	:	616-631-7760
Fax Number	:

Provider Business Practice Location Address
First Line	:	1444 MICHIGAN ST NE STE 8
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2028
Country	:	US
Telephone Number	:	616-631-7760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	11/06/2019

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