Healthcare Provider Details

I. General information

NPI: 1962535856
Provider Name (Legal Business Name): DAVID UITDEFLESCH MA, LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 KRAFT AVE SE STE 186
GRAND RAPIDS MI
49512-2076
US

IV. Provider business mailing address

2828 KRAFT AVE SE STE 186
GRAND RAPIDS MI
49512-2076
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-9550
  • Fax: 616-949-9551
Mailing address:
  • Phone: 616-949-9550
  • Fax: 616-949-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361001214
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: