Healthcare Provider Details

I. General information

NPI: 1710222971
Provider Name (Legal Business Name): EDMEE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 E PARIS AVE SE SUITE 101
GRAND RAPIDS MI
49546-2414
US

IV. Provider business mailing address

2323 E PARIS AVE SE SUITE 101
GRAND RAPIDS MI
49546-2414
US

V. Phone/Fax

Practice location:
  • Phone: 616-242-0099
  • Fax: 616-242-0099
Mailing address:
  • Phone: 616-242-0099
  • Fax: 616-242-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013480
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301078556
License Number StateMI

VIII. Authorized Official

Name: STACEY MARQUEE
Title or Position: PSYCHOLOGIST/ADMINISTRATOR
Credential: MA LLP
Phone: 616-443-8968