Healthcare Provider Details

I. General information

NPI: 1760466056
Provider Name (Legal Business Name): MICHAEL M MAKEDONSKY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE SUITE 222
GRAND RAPIDS MI
49546-5940
US

IV. Provider business mailing address

PO BOX 1767
GRAND RAPIDS MI
49501-1767
US

V. Phone/Fax

Practice location:
  • Phone: 616-957-0730
  • Fax: 616-957-1057
Mailing address:
  • Phone: 616-235-2090
  • Fax: 616-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number000656
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: