Healthcare Provider Details

I. General information

NPI: 1942535323
Provider Name (Legal Business Name): DAVID CRAIG BOERSMA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 BALL AVE NE
GRAND RAPIDS MI
49503-1307
US

IV. Provider business mailing address

703 BALL AVE NE
GRAND RAPIDS MI
49503-1307
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-0207
  • Fax: 616-632-6361
Mailing address:
  • Phone: 616-774-0207
  • Fax: 616-632-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number6301006074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: