Healthcare Provider Details

I. General information

NPI: 1265610422
Provider Name (Legal Business Name): MY THI LIEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2008
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 PLAINFIELD AVE NE SUITE C
GRAND RAPIDS MI
49525-1644
US

IV. Provider business mailing address

4701 PLAINFIELD AVE NE SUITE C
GRAND RAPIDS MI
49525-1644
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-3365
  • Fax: 616-361-3395
Mailing address:
  • Phone: 616-361-3365
  • Fax: 616-361-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013608
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301013608
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number6301013608
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301013608
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6301013608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: