Healthcare Provider Details

I. General information

NPI: 1558600973
Provider Name (Legal Business Name): HULST PSYCHOLOGY AND ASSESSMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 CASCADE RD SE SUITE 230
GRAND RAPIDS MI
49546-3708
US

IV. Provider business mailing address

4940 CASCADE RD SE SUITE 230
GRAND RAPIDS MI
49546-3708
US

V. Phone/Fax

Practice location:
  • Phone: 616-803-0643
  • Fax:
Mailing address:
  • Phone: 616-803-0643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013253
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013813
License Number StateMI

VIII. Authorized Official

Name: MRS. SUSIE HULST
Title or Position: PSYCHOLOGIST
Credential: MA
Phone: 616-901-0336