MEDICARE: GREAT LAKES BEHAVIORAL HEALTH PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1609268754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES BEHAVIORAL HEALTH PLC

Provider Business Mailing Address
First Line	:	678 FRONT AVE NW
Second Line	:	SUITE 365
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-920-1816
Fax Number	:

Provider Business Practice Location Address
First Line	:	678 FRONT AVE NW
Second Line	:	SUITE 365
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-5325
Country	:	US
Telephone Number	:	616-920-1816
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID VANDER VELDE
Credential	:	DO
Telephone Number	:	616-920-1816

Provider Enumeration Date	:	02/26/2015
Last Update Date	:	06/02/2015

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