Healthcare Provider Details

I. General information

NPI: 1720152119
Provider Name (Legal Business Name): VICKI LYNN NELSON SMEBY MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICKI NELSON SMEBY MA LLP

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 CASCADE RD SE BLDG 2 STE 1
GRAND RAPIDS MI
49546-3666
US

IV. Provider business mailing address

2208 STRATFORD CT SE
EAST GRAND RAPIDS MI
49506-4133
US

V. Phone/Fax

Practice location:
  • Phone: 616-460-1819
  • Fax: 616-942-9490
Mailing address:
  • Phone: 616-460-1819
  • Fax: 616-942-9490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301010861
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: