Healthcare Provider Details

I. General information

NPI: 1235046863
Provider Name (Legal Business Name): MATTHEW J VANDENELST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4764 FULTON ST E STE 204
ADA MI
49301-9086
US

IV. Provider business mailing address

1943 GEORGETOWN DR SE BLDG 25
GRAND RAPIDS MI
49506-5409
US

V. Phone/Fax

Practice location:
  • Phone: 616-200-4433
  • Fax:
Mailing address:
  • Phone: 616-446-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: