Healthcare Provider Details

I. General information

NPI: 1699140541
Provider Name (Legal Business Name): VANESSA LYNNE ABBOTT LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 3 MILE RD NW
GRAND RAPIDS MI
49544-1614
US

IV. Provider business mailing address

2045 OLD VALLEY CT SE
KENTWOOD MI
49508-6531
US

V. Phone/Fax

Practice location:
  • Phone: 616-780-6563
  • Fax:
Mailing address:
  • Phone: 616-780-6563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: