Provider Demographics
NPI:1639390743
Name:WOLTHUIS, RANDALL L (PHD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:WOLTHUIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PARCHMENT DRIVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3663
Mailing Address - Country:US
Mailing Address - Phone:616-957-9112
Mailing Address - Fax:616-957-2409
Practice Address - Street 1:8202 TRIPLE L TRL SE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:MI
Practice Address - Zip Code:49302-9551
Practice Address - Country:US
Practice Address - Phone:616-275-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006480103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D145940OtherBCBS PIN