Healthcare Provider Details

I. General information

NPI: 1265156129
Provider Name (Legal Business Name): LILLIAN VENEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4934 LUXEMBURG ST SE
GRAND RAPIDS MI
49546-8406
US

IV. Provider business mailing address

4150 VALLEY VISTA DR APT 302
HUDSONVILLE MI
49426-7976
US

V. Phone/Fax

Practice location:
  • Phone: 616-215-0444
  • Fax:
Mailing address:
  • Phone: 269-945-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: