Healthcare Provider Details

I. General information

NPI: 1205017738
Provider Name (Legal Business Name): PSYCHOLOGY ASSOCIATES OF GRAND RAPIDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3663
US

IV. Provider business mailing address

1000 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3663
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-9112
  • Fax: 616-957-2409
Mailing address:
  • Phone: 616-957-9112
  • Fax: 616-957-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CRAIG A DE WITT
Title or Position: OWNER
Credential: PSY.D.
Phone: 616-957-9112