Provider Demographics
NPI:1821501933
Name:CHRISTINE DIEVENDORF WEISS, PLLC
Entity Type:Organization
Organization Name:CHRISTINE DIEVENDORF WEISS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:DIEVENDORF
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:269-520-0050
Mailing Address - Street 1:5400 HOLIDAY TER STE 200A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2161
Mailing Address - Country:US
Mailing Address - Phone:269-520-0050
Mailing Address - Fax:269-520-0051
Practice Address - Street 1:5400 HOLIDAY TER STE 200A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2161
Practice Address - Country:US
Practice Address - Phone:269-520-0050
Practice Address - Fax:269-520-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-10
Last Update Date:2020-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011020101YM0800X
MI6301013930103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty