Healthcare Provider Details

I. General information

NPI: 1831536051
Provider Name (Legal Business Name): MALLORY VREDEVELD M.A., L.L.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2013
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E WASHINGTON AVE SUITE 284
JACKSON MI
49201-2393
US

IV. Provider business mailing address

209 E WASHINGTON AVE SUITE 284
JACKSON MI
49201-2393
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-6444
  • Fax: 517-789-5049
Mailing address:
  • Phone: 517-789-6444
  • Fax: 517-789-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401012772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: