MEDICARE: MRS. ANDREA JOYCE DATTADEEN LLPC

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	101Y00000X	Counselor	6401015974	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6401015974	OTHER	MI	STATE THERAPIST LICENSE

General Provider Information

NPI Number	:	1902335060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANDREA JOYCE DATTADEEN LLPC

Provider Business Mailing Address
First Line	:	194 W 18TH ST
Second Line	:
City	:	HOLLAND
State	:	MI
Zip	:	49423-4123
Country	:	US
Telephone Number	:	616-510-8291
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 EASTERN AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3632
Country	:	US
Telephone Number	:	616-988-3433
Fax Number	:	313-899-7087

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

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/12/2017

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