Healthcare Provider Details

I. General information

NPI: 1639713613
Provider Name (Legal Business Name): KRISTIN NOEL LINDBLOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 BURTON ST SE STE 101
GRAND RAPIDS MI
49546-4800
US

IV. Provider business mailing address

1210 DALE CT NE
GRAND RAPIDS MI
49505-5445
US

V. Phone/Fax

Practice location:
  • Phone: 616-278-1201
  • Fax:
Mailing address:
  • Phone: 616-291-6172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: