Healthcare Provider Details

I. General information

NPI: 1457157430
Provider Name (Legal Business Name): BEATRICE PAVLIK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EDISON AVE NW
GRAND RAPIDS MI
49504-3918
US

IV. Provider business mailing address

4140 VALLEY VISTA DR APT 103
HUDSONVILLE MI
49426-7975
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-2475
  • Fax:
Mailing address:
  • Phone: 630-853-3269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008201
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: