Healthcare Provider Details

I. General information

NPI: 1396351995
Provider Name (Legal Business Name): AUDREY JOY-BAKER VANDER WAL MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 E PARIS AVE SE STE 203
GRAND RAPIDS MI
49546-2426
US

IV. Provider business mailing address

184 GLENDALE ST
HOLLAND MI
49423-3031
US

V. Phone/Fax

Practice location:
  • Phone: 616-816-1758
  • Fax: 616-333-7685
Mailing address:
  • Phone: 719-310-4557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401223152
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: