Healthcare Provider Details

I. General information

NPI: 1972651396
Provider Name (Legal Business Name): ROCHELLE G MANOR PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 EAGLE RUN DR NE SUITE C
GRAND RAPIDS MI
49525-7053
US

IV. Provider business mailing address

3351 EAGLE RUN DR NE SUITE C
GRAND RAPIDS MI
49525-7053
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-8920
  • Fax: 616-365-8971
Mailing address:
  • Phone: 616-365-8920
  • Fax: 616-365-8971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301009319
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: