Healthcare Provider Details

I. General information

NPI: 1427634807
Provider Name (Legal Business Name): KATHERINE MAE SANDISON MA, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 NORTHLAND DR NE STE A
GRAND RAPIDS MI
49525-1096
US

IV. Provider business mailing address

2248 ONTONAGON AVE SE
GRAND RAPIDS MI
49506-5368
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-5001
  • Fax: 616-361-2166
Mailing address:
  • Phone: 616-295-0832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6361007821
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: