Provider Demographics
NPI:1083206270
Name:VISSER, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:VISSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1221
Mailing Address - Country:US
Mailing Address - Phone:616-300-5495
Mailing Address - Fax:
Practice Address - Street 1:2880 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1221
Practice Address - Country:US
Practice Address - Phone:616-300-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2024-11-21
Deactivation Date:2022-06-06
Deactivation Code:
Reactivation Date:2022-10-14
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist