Healthcare Provider Details

I. General information

NPI: 1205985397
Provider Name (Legal Business Name): MICHAEL JAMES VREDEVOOGD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
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

50081 SASS RD
CHESTERFIELD MI
48047-1946
US

V. Phone/Fax

Practice location:
  • Phone: 586-741-0295
  • Fax: 586-792-5190
Mailing address:
  • Phone: 586-530-7919
  • Fax: 586-792-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number63010006531
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: