Healthcare Provider Details

I. General information

NPI: 1851748768
Provider Name (Legal Business Name): HEATHER DERMYER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 CENTENNIAL RDG #205
GRAND RAPIDS MI
49546-7098
US

IV. Provider business mailing address

3330 CENTENNIAL RDG #205
GRAND RAPIDS MI
49546-7098
US

V. Phone/Fax

Practice location:
  • Phone: 906-250-3191
  • Fax:
Mailing address:
  • Phone: 906-250-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301014186
License Number StateMI

VIII. Authorized Official

Name: DR. HEATHER LYNN DERMYER
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 906-250-3191