Provider Demographics
NPI:1205985397
Name:VREDEVOOGD, MICHAEL JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:VREDEVOOGD
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 1:50081 SASS RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1946
Mailing Address - Country:US
Mailing Address - Phone:586-530-7919
Mailing Address - Fax:586-792-5190
Practice Address - Street 1:36385 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-4635
Practice Address - Country:US
Practice Address - Phone:586-741-0295
Practice Address - Fax:586-792-5190
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010006531103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680EO1478OtherBLUE CROSS BLUE SHIELD
MIN84270001Medicare ID - Type Unspecified