Healthcare Provider Details

I. General information

NPI: 1033701396
Provider Name (Legal Business Name): MATT DEHOOG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 PARCHMENT DR SE STE 100
GRAND RAPIDS MI
49546-2307
US

IV. Provider business mailing address

4467 BRAEBURN DR SE
GRAND RAPIDS MI
49546-2279
US

V. Phone/Fax

Practice location:
  • Phone: 616-366-4226
  • Fax:
Mailing address:
  • Phone: 616-581-7687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: