Healthcare Provider Details

I. General information

NPI: 1861629263
Provider Name (Legal Business Name): LINDA SUE HAVEMAN PH.D., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 EAGLE PARK DR NE SUITE 117
GRAND RAPIDS MI
49525-4569
US

IV. Provider business mailing address

3813 RAIN TREE AVE
HUDSONVILLE MI
49426-8481
US

V. Phone/Fax

Practice location:
  • Phone: 616-530-2224
  • Fax: 616-825-6164
Mailing address:
  • Phone: 616-862-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: