Basic Information
| Provider Information | |||||||||
| NPI: | 1841434305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OPPEWAL | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | BOUWSMA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA LLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | OPPEWAL | ||||||||
| OtherFirstName: | LIZ | ||||||||
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| OtherCredential: | MA LLP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 644 HAWTHORNE ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495033412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164438379 | ||||||||
| FaxNumber: | 2696864601 | ||||||||
| Practice Location | |||||||||
| Address1: | 277 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696735092 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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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 | 6301009033 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.