Healthcare Provider Details

I. General information

NPI: 1538511019
Provider Name (Legal Business Name): DAVID CHADDERDON MA,LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLIDAY TER
KALAMAZOO MI
49009-2196
US

IV. Provider business mailing address

6801 MARLOW ST
PORTAGE MI
49024-3340
US

V. Phone/Fax

Practice location:
  • Phone: 269-372-4140
  • Fax: 269-372-0390
Mailing address:
  • Phone: 269-929-8745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301006515
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: