Healthcare Provider Details

I. General information

NPI: 1609268754
Provider Name (Legal Business Name): GREAT LAKES BEHAVIORAL HEALTH PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 FRONT AVE NW SUITE 365
GRAND RAPIDS MI
49504-5325
US

IV. Provider business mailing address

678 FRONT AVE NW SUITE 365
GRAND RAPIDS MI
49504-5325
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-1816
  • Fax:
Mailing address:
  • Phone: 616-920-1816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID VANDER VELDE
Title or Position: OWNER
Credential: DO
Phone: 616-920-1816