Healthcare Provider Details

I. General information

NPI: 1457940496
Provider Name (Legal Business Name): ADHDONLINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5619 BALSAM DR
HUDSONVILLE MI
49426-1128
US

IV. Provider business mailing address

5619 BALSAM DR
HUDSONVILLE MI
49426-1128
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-2935
  • Fax:
Mailing address:
  • Phone: 616-229-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DEBRA DAVISSON
Title or Position: BILLER/CODER
Credential:
Phone: 517-740-0184