Provider Demographics
NPI:1174160550
Name:RANDALL WOLTHUIS, PH.D. LLC
Entity type:Organization
Organization Name:RANDALL WOLTHUIS, PH.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WOLTHUIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-275-2113
Mailing Address - Street 1:8202 TRIPLE L TRL SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9551
Mailing Address - Country:US
Mailing Address - Phone:616-250-2217
Mailing Address - Fax:
Practice Address - Street 1:8202 TRIPLE L TRL SE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:MI
Practice Address - Zip Code:49302-9551
Practice Address - Country:US
Practice Address - Phone:616-275-2113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty