Healthcare Provider Details

I. General information

NPI: 1780344465
Provider Name (Legal Business Name): LYNNITH MAXIMUS TEETSEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 FAST ICE DR
MIDLAND MI
48642-6167
US

IV. Provider business mailing address

301 S CRAPO ST STE 200
MOUNT PLEASANT MI
48858-2941
US

V. Phone/Fax

Practice location:
  • Phone: 989-631-2320
  • Fax:
Mailing address:
  • Phone: 989-772-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1780344465
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: