Provider Demographics
NPI:1104515378
Name:FEDDEMA, VICTORIA ROSE
Entity type:Individual
Prefix:MISS
First Name:VICTORIA
Middle Name:ROSE
Last Name:FEDDEMA
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 1:1616 BOSTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4415
Mailing Address - Country:US
Mailing Address - Phone:616-245-6843
Mailing Address - Fax:
Practice Address - Street 1:420 PLYMOUTH AVE NE # 6028
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6028
Practice Address - Country:US
Practice Address - Phone:616-888-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health