Healthcare Provider Details

I. General information

NPI: 1437324506
Provider Name (Legal Business Name): MICHAEL K. KIVINEN MA, LLP, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 EAGLE RUN DR SUITE 200
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

3210 EAGLE RUN DR SUITE 200
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-1200
  • Fax: 616-957-1297
Mailing address:
  • Phone: 616-957-1200
  • Fax: 616-957-1297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number630101063
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801035811
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: