Provider Demographics
NPI:1871646307
Name:VANTREESE, JIM CHARLES (PHD)
Entity Type:Individual
Prefix:MR
First Name:JIM
Middle Name:CHARLES
Last Name:VANTREESE
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 1:4845 SNYDER AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-9502
Mailing Address - Country:US
Mailing Address - Phone:231-924-6920
Mailing Address - Fax:
Practice Address - Street 1:4845 SNYDER AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-9502
Practice Address - Country:US
Practice Address - Phone:231-924-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002725103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620F24513OtherBCBSM
MI0F14513Medicare ID - Type Unspecified