Provider Demographics
NPI:1659535540
Name:PEDIATRIC PSYCHOLOGISTS OF WEST MICHIGAN, PLC
Entity Type:Organization
Organization Name:PEDIATRIC PSYCHOLOGISTS OF WEST MICHIGAN, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:616-262-2494
Mailing Address - Street 1:2090 CELEBRATION DR NE STE 212
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9200
Mailing Address - Country:US
Mailing Address - Phone:616-262-2494
Mailing Address - Fax:
Practice Address - Street 1:2090 CELEBRATION DR NE STE 212
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9200
Practice Address - Country:US
Practice Address - Phone:616-262-2494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty