1013147495 NPI number — ARDEAN BETH BROCK-VANDERWALL M.DIV., M.A.

Table of content: ARDEAN BETH BROCK-VANDERWALL M.DIV., M.A. (NPI 1013147495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013147495 NPI number — ARDEAN BETH BROCK-VANDERWALL M.DIV., M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK-VANDERWALL
Provider First Name:
ARDEAN
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.DIV., M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROCK-VANDERWALL
Provider Other First Name:
ARDEAN
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.DIV., M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013147495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3208 WOODBERRY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-893-6420
Provider Business Mailing Address Fax Number:
616-891-9676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2828 KRAFT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-949-9550
Provider Business Practice Location Address Fax Number:
616-949-9551
Provider Enumeration Date:
07/20/2009

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: 101YP2500X , with the licence number:  6401011131 , 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)





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