Basic Information
| Provider Information | |||||||||
| NPI: | 1669414082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | MA, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1530 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490062065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693436700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301011880 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | P10D112750 | 01 | MI | BC/BS | OTHER |