Healthcare Provider Details

I. General information

NPI: 1508282120
Provider Name (Legal Business Name): DOUGLAS VANDERLOOVEN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N 4TH AVE
ANN ARBOR MI
48104-5503
US

IV. Provider business mailing address

555 TOWNER ST
YPSILANTI MI
48198-5752
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3750
  • Fax:
Mailing address:
  • Phone: 734-431-0087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801113753
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: