Healthcare Provider Details

I. General information

NPI: 1679478937
Provider Name (Legal Business Name): BRENDA KAY THOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 S BEECHTREE ST
GRAND HAVEN MI
49417-2843
US

IV. Provider business mailing address

PO BOX 3
SPRING LAKE MI
49456-0003
US

V. Phone/Fax

Practice location:
  • Phone: 616-850-5142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: