Healthcare Provider Details

I. General information

NPI: 1013064369
Provider Name (Legal Business Name): DIANA L CALCOTT MA LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 JORDAN LAKE ST
LAKE ODESSA MI
48849-1270
US

IV. Provider business mailing address

1773 WOODSIDE TRL NW
GRAND RAPIDS MI
49504-2580
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-7410
  • Fax:
Mailing address:
  • Phone: 616-453-1835
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401005659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: