Healthcare Provider Details

I. General information

NPI: 1962453548
Provider Name (Legal Business Name): KIMBERLY ANNE-HANSEN HOLWERDA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 BALDWIN ST
JENISON MI
49428-8901
US

IV. Provider business mailing address

1293 MONTE CARLO DR
JENISON MI
49428-8301
US

V. Phone/Fax

Practice location:
  • Phone: 616-457-0016
  • Fax:
Mailing address:
  • Phone: 616-667-2705
  • Fax: 616-667-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberL136241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: