Healthcare Provider Details

I. General information

NPI: 1154870780
Provider Name (Legal Business Name): KAITLIN ELIZABETH VREDEVELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

IV. Provider business mailing address

2438 ALMONT AVE SE
GRAND RAPIDS MI
49507-3941
US

V. Phone/Fax

Practice location:
  • Phone: 269-598-9431
  • Fax:
Mailing address:
  • Phone: 269-598-9431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016417
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: