MEDICARE: KATHERINE G PASTOOR MA, LLP

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	103T00000X	Psychologist	6301017840	MI

General Provider Information

NPI Number	:	1770129009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE G PASTOOR MA, LLP

Provider Business Mailing Address
First Line	:	453 GREENMEADOW CT SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-8050
Country	:	US
Telephone Number	:	616-460-6896
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 44TH ST SE STE C
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49548-4371
Country	:	US
Telephone Number	:	616-460-6896
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	11/21/2019

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