Healthcare Provider Details

I. General information

NPI: 1295979276
Provider Name (Legal Business Name): CELESTE ICIEK LINDER MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

4716 HERITAGE MEADOW DR
HOLLAND MI
49423-8738
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5000
  • Fax:
Mailing address:
  • Phone: 616-204-0395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361004502
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: