Healthcare Provider Details

I. General information

NPI: 1821501933
Provider Name (Legal Business Name): CHRISTINE DIEVENDORF WEISS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 05/03/2020
Certification Date: 05/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 HOLIDAY TER STE 200A
KALAMAZOO MI
49009-2161
US

IV. Provider business mailing address

5400 HOLIDAY TER STE 200A
KALAMAZOO MI
49009-2161
US

V. Phone/Fax

Practice location:
  • Phone: 269-520-0050
  • Fax: 269-520-0051
Mailing address:
  • Phone: 269-520-0050
  • Fax: 269-520-0051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401011020
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301013930
License Number StateMI

VIII. Authorized Official

Name: CHRISTINE DIEVENDORF WEISS
Title or Position: OWNER
Credential: MA
Phone: 269-520-0050