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General NPI Number Information
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NPI Number | 1184683351
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Entity Type | Individual
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Provider Name | KRISTIN M MECKLENBURG MA LLP
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Gender | Female
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Dates
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Enumeration Date | 03/17/2006
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Last Update Date | 07/05/2024
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Provider Practice Location Address
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Address Line | 4175 PARKWAY PLACE DR SW STE 100
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City | GRANDVILLE
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State | MI
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Zip | 49418-2382
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Country | US
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Telephone | 616-371-5166
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 120125
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City | GRAND RAPIDS
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State | MI
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Zip | 49528-0103
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Country | US
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Telephone | 616-942-8060
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Fax | 616-942-6690
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6361005978
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License Number State | MI
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