Basic Information
| Provider Information | |||||||||
| NPI: | 1760431282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDARBROOK PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 120125 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495280103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169428060 | ||||||||
| FaxNumber: | 6169426690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 PECK ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494412507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169428060 | ||||||||
| FaxNumber: | 6169426690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SWISHER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING | ||||||||
| AuthorizedOfficialTelephone: | 6169428060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.