1023101078 NPI number — KEVIN D VREDEVELD LMSW

Table of content: KEVIN D VREDEVELD LMSW (NPI 1023101078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023101078 NPI number — KEVIN D VREDEVELD LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VREDEVELD
Provider First Name:
KEVIN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023101078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 MICHIGAN AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49017-3602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-966-1460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 MICHIGAN AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49017-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-966-1460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6801070171 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 800D162220 . This is a "BC/BS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".