Healthcare Provider Details

I. General information

NPI: 1104060649
Provider Name (Legal Business Name): PATRICIA G ESPINOZA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 BALDWIN ST
JENISON MI
49428-8901
US

IV. Provider business mailing address

1726 NORTH BAY DRIVE
HUDSONVILLE MI
49426
US

V. Phone/Fax

Practice location:
  • Phone: 616-457-0016
  • Fax: 616-457-1950
Mailing address:
  • Phone: 616-262-7572
  • Fax: 616-457-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number63010112207
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: