MEDICARE: MR. WESLEY BURDETTE VANDENBURG MA IN COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1639782147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WESLEY BURDETTE VANDENBURG MA IN COUNSELING

Provider Business Mailing Address
First Line	:	885 BEECH ST
Second Line	:
City	:	LAKE ODESSA
State	:	MI
Zip	:	48849-9431
Country	:	US
Telephone Number	:	616-558-7464
Fax Number	:

Provider Business Practice Location Address
First Line	:	885 BEECH ST
Second Line	:
City	:	LAKE ODESSA
State	:	MI
Zip	:	48849-9431
Country	:	US
Telephone Number	:	616-558-7464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2020
Last Update Date	:	08/25/2020

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