Healthcare Provider Details

I. General information

NPI: 1902836372
Provider Name (Legal Business Name): DAVID L NYENHUIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 CHERRY ST SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

245 STATE ST SE STE 1A
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5050
  • Fax: 312-704-2737
Mailing address:
  • Phone: 312-704-2885
  • Fax: 312-704-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071004082
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301015194
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: