Michael James Vredevoogd, PH.D.

Primary specialty

Clinical NeuropsychologistTaxonomy code 103G00000X

License

63010006531 Issued in MI

Practice address

36385 Harper Ave
Clinton Township, MI 48035-4635

Phone

(586) 741-0295

Fax

(586) 792-5190

NPI assigned

Jan 9, 2007

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

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

{
    "created_epoch": "1168300800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1205985397",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "50081 SASS RD",
            "city": "CHESTERFIELD",
            "state": "MI",
            "postal_code": "480471946",
            "telephone_number": "586-530-7919",
            "fax_number": "586-792-5190"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36385 HARPER AVE",
            "city": "CLINTON TOWNSHIP",
            "state": "MI",
            "postal_code": "480354635",
            "telephone_number": "586-741-0295",
            "fax_number": "586-792-5190"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VREDEVOOGD",
        "first_name": "MICHAEL",
        "middle_name": "JAMES",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-01-09",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "MI",
            "license": "63010006531",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "680EO1478",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Neuropsychologist in Clinton Township, MI
• Providers in Clinton Township, MI by specialty
• Clinical Neuropsychologist in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.