Basic Information
| Provider Information | |||||||||
| NPI: | 1811451339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIKMA | ||||||||
| FirstName: | ANNALISE | ||||||||
| MiddleName: | J | ||||||||
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| OtherLastName: | VANENK | ||||||||
| OtherFirstName: | ANNALISE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3809 LAKE EASTBROOK BLVD SE STE A | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465931 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3809 LAKE EASTBROOK BLVD SE STE A | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166048492 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2019 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6362009404 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.