Healthcare Provider Details

I. General information

NPI: 1174160550
Provider Name (Legal Business Name): RANDALL WOLTHUIS, PH.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 TRIPLE L TRL SE
ALTO MI
49302-9551
US

IV. Provider business mailing address

8202 TRIPLE L TRL SE
ALTO MI
49302-9551
US

V. Phone/Fax

Practice location:
  • Phone: 616-275-2113
  • Fax:
Mailing address:
  • Phone: 616-250-2217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL LEE WOLTHUIS
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 616-275-2113