Healthcare Provider Details

I. General information

NPI: 1366486755
Provider Name (Legal Business Name): MICHELLE JEANINE DENNIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4127 EMBASSY DR SE
GRAND RAPIDS MI
49546-2418
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-3200
  • Fax:
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: