Provider Demographics
NPI:1902836372
Name:NYENHUIS, DAVID L (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:NYENHUIS
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 1:245 STATE ST SE
Mailing Address - Street 2:STE 1A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:312-704-2885
Mailing Address - Fax:312-704-2737
Practice Address - Street 1:220 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-5050
Practice Address - Fax:312-704-2737
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004082103G00000X
MI6301015194103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06245Medicare ID - Type Unspecified
MI0P32930475Medicare PIN