Basic Information
| Provider Information | |||||||||
| NPI: | 1659886232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEHAAN | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | M.A. LLPC, LLMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2867 RIVERWOODS DR NE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493419294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168228592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4101006752 | MI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | 6401016266 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.