Provider Demographics
NPI:1609268754
Name:GREAT LAKES BEHAVIORAL HEALTH PLC
Entity Type:Organization
Organization Name:GREAT LAKES BEHAVIORAL HEALTH PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER VELDE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-920-1816
Mailing Address - Street 1:678 FRONT AVE NW
Mailing Address - Street 2:SUITE 365
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5325
Mailing Address - Country:US
Mailing Address - Phone:616-920-1816
Mailing Address - Fax:
Practice Address - Street 1:678 FRONT AVE NW
Practice Address - Street 2:SUITE 365
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5325
Practice Address - Country:US
Practice Address - Phone:616-920-1816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty