Healthcare Provider Details

I. General information

NPI: 1417848763
Provider Name (Legal Business Name): WESTSIDE NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CORPORATE EXCHANGE BLVD SE STE 201
GRAND RAPIDS MI
49512-5506
US

IV. Provider business mailing address

5030 CORPORATE EXCHANGE BLVD SE STE 201
GRAND RAPIDS MI
49512-5506
US

V. Phone/Fax

Practice location:
  • Phone: 616-287-4164
  • Fax:
Mailing address:
  • Phone: 616-287-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. VELISA JOHNSON
Title or Position: CLINICAL NEUROPSYCHOLOGIST/OWNER
Credential: PHD, ABPP-CN
Phone: 616-287-4164