Provider Demographics
NPI:1437324506
Name:KIVINEN, MICHAEL K (MA, LLP, CHT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:K
Last Name:KIVINEN
Suffix:
Gender:M
Credentials:MA, LLP, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 EAGLE RUN DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-957-1200
Mailing Address - Fax:616-957-1297
Practice Address - Street 1:3210 EAGLE RUN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-957-1200
Practice Address - Fax:616-957-1297
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI630101063103TC0700X
MI68010358111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE