Provider Demographics
NPI:1760466056
Name:MAKEDONSKY, MICHAEL M (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:MAKEDONSKY
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:PO BOX 1767
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1767
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:SUITE 222
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5940
Practice Address - Country:US
Practice Address - Phone:616-957-0730
Practice Address - Fax:616-957-1057
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI000656103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical