Healthcare Provider Details

I. General information

NPI: 1760489793
Provider Name (Legal Business Name): THERESA JOAN ANDERSON-VARNEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

IV. Provider business mailing address

1019 PARCHMENT DR SE
GRAND RAPIDS MI
49546-3664
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-8868
  • Fax: 616-285-8875
Mailing address:
  • Phone: 616-285-8868
  • Fax: 616-285-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301007309
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: