Healthcare Provider Details

I. General information

NPI: 1013147495
Provider Name (Legal Business Name): ARDEAN BETH BROCK-VANDERWALL M.DIV., M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ARDEAN BETH BROCK-VANDERWALL M.DIV., M.A.

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 KRAFT AVE.
GRAND RAPIDS MI
49512
US

IV. Provider business mailing address

3208 WOODBERRY DRIVE
GRAND RAPIDS MI
49512
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-9550
  • Fax: 616-949-9551
Mailing address:
  • Phone: 616-893-6420
  • Fax: 616-891-9676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: