Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 6301002554 | MI |
N | 103T00000X | Psychologist | 6301002554 | MI |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 6301002554 | MI |
N | 103G00000X | Clinical Psychologist | 6301002554 | MI |
N | 103TC0700X | Clinical Psychologist | 6301002554 | MI |
N | 104100000X | Social Worker | MI | |
N | 1041C0700X | Clinical Social Worker | 6301002554 | MI |
NPI | 1215002811 |
---|---|
Provider Name | Mrs. Susan De Waard |
First Address | Grand Rapids, MI 49503-4513 |
Second Address | Grand Rapids, MI 49503-4513 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 08/07/2007 |