Healthcare Provider Details

I. General information

NPI: 1992108872
Provider Name (Legal Business Name): INTEGRATIVE PSYCHOTHERAPY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 BRETON RD SE
GRAND RAPIDS MI
49546-5633
US

IV. Provider business mailing address

2707 BRETON RD SE
GRAND RAPIDS MI
49546-5633
US

V. Phone/Fax

Practice location:
  • Phone: 616-822-9714
  • Fax:
Mailing address:
  • Phone: 616-822-9714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301004073
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN C. WEIKS
Title or Position: OWNER
Credential: ED.D.
Phone: 616-822-9714