Healthcare Provider Details

I. General information

NPI: 1649247875
Provider Name (Legal Business Name): KAREN M VANDEUSEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4467 CASCADE RD SE SUITE 4481
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

PO BOX 120125
GRAND RAPIDS MI
49528-0103
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-8060
  • Fax: 616-942-6690
Mailing address:
  • Phone: 616-942-8060
  • Fax: 616-942-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: