Provider Demographics
NPI:1952429516
Name:PERSENAIRE, VERONICA RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:RODRIGUEZ
Last Name:PERSENAIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 EAST PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-940-0238
Practice Address - Fax:616-245-0450
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI6301009474103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical