Healthcare Provider Details

I. General information

NPI: 1063016046
Provider Name (Legal Business Name): TRISHA NICHOLE TANIS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CASCADE WEST PKWY SE STE 240
GRAND RAPIDS MI
49546-2166
US

IV. Provider business mailing address

500 CASCADE WEST PKWY SE STE 240
GRAND RAPIDS MI
49546-2166
US

V. Phone/Fax

Practice location:
  • Phone: 616-591-9000
  • Fax:
Mailing address:
  • Phone: 616-591-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6351004500
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: