NPIMap

Organization Active NPI

Psychology Associates of Grand Rapids PC

  • Psychologist
  • Grand Rapids, MI
National Provider Identifier
1205017738
Registry record updated Mar 9, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
Legal business name
PSYCHOLOGY ASSOCIATES OF GRAND RAPIDS PC
Practice address
1000 Parchment Dr SE
Grand Rapids, MI 49546-3663
Phone
(616) 957-9112
Fax
(616) 957-2409
NPI assigned
Nov 27, 2007
Last updated
Mar 9, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Craig A De Witt, PSY.D.NPI 1679621213
Title
Owner
Phone
(616) 957-9112

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric/Mental Health Nurse Practitioner 363LP0808X NU
Psychologist 103T00000X NU Primary
Psychiatry Physician 2084P0800X NU

Addresses

Primary practice location

1000 Parchment Dr SE
Grand Rapids, MI 49546-3663

Mailing address

1000 Parchment Dr SE
Grand Rapids, MI 49546-3663
Phone (616) 957-9112

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050127000854 MI Part B Supplier - Clinic/Group Practice 6608826557 Receives reassigned benefits from 21 practitioners
1 other NPI on this enrollment
Practice locations: Grand Rapids, MI

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Psychology Associates of Grand Rapids3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196121600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1457481600000",
    "number": "1205017738",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1000 PARCHMENT DR SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495463663",
            "telephone_number": "616-957-9112",
            "fax_number": "616-957-2409"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 PARCHMENT DR SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495463663",
            "telephone_number": "616-957-9112",
            "fax_number": "616-957-2409"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PSYCHOLOGY ASSOCIATES OF GRAND RAPIDS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-27",
        "last_updated": "2016-03-09",
        "status": "A",
        "authorized_official_last_name": "DE WITT",
        "authorized_official_first_name": "CRAIG",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "616-957-9112",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.