Healthcare Provider Details

I. General information

NPI: 1336030196
Provider Name (Legal Business Name): DERAE K CHAPMAN MA, TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 FULLER AVE NE STE 208
GRAND RAPIDS MI
49505-3458
US

IV. Provider business mailing address

2920 FULLER AVE NE STE 208
GRAND RAPIDS MI
49505-3458
US

V. Phone/Fax

Practice location:
  • Phone: 616-551-2916
  • Fax: 616-226-4919
Mailing address:
  • Phone: 616-551-2916
  • Fax: 616-226-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362010194
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: