Healthcare Provider Details

I. General information

NPI: 1114108974
Provider Name (Legal Business Name): MICHAEL VREDEVOOGD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36385 HARPER AVE
CLINTON TOWNSHIP MI
48035-4635
US

IV. Provider business mailing address

36385 HARPER AVE
CLINTON TOWNSHIP MI
48035-4635
US

V. Phone/Fax

Practice location:
  • Phone: 586-741-0295
  • Fax:
Mailing address:
  • Phone: 586-741-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number63010066531
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number63010066531
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL JAMES VREDEVOOGD
Title or Position: PRESIDENT
Credential:
Phone: 586-741-0295