Healthcare Provider Details

I. General information

NPI: 1871613968
Provider Name (Legal Business Name): LIDDERDALE CONSULTING PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 3 MILE RD NW STE D
GRAND RAPIDS MI
49544-8219
US

IV. Provider business mailing address

57 COURTLAND ST UNIT 794
ROCKFORD MI
49341-5027
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-9193
  • Fax: 616-426-9455
Mailing address:
  • Phone: 616-426-9193
  • Fax: 616-426-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301012277
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301014348
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012277
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301014348
License Number StateMI

VIII. Authorized Official

Name: MELISSA ANN LIDDERDALE
Title or Position: PSYCHOLOGIST/OWNER
Credential: PHD
Phone: 616-426-9193