Healthcare Provider Details

I. General information

NPI: 1659535540
Provider Name (Legal Business Name): PEDIATRIC PSYCHOLOGISTS OF WEST MICHIGAN, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 CELEBRATION DR NE STE 212
GRAND RAPIDS MI
49525-9200
US

IV. Provider business mailing address

2090 CELEBRATION DR NE STE 212
GRAND RAPIDS MI
49525-9200
US

V. Phone/Fax

Practice location:
  • Phone: 616-262-2494
  • Fax:
Mailing address:
  • Phone: 616-262-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY ANNE GRIFFIN
Title or Position: SENIOR PARTNER
Credential: M.A.
Phone: 616-262-2494