Healthcare Provider Details

I. General information

NPI: 1497774509
Provider Name (Legal Business Name): CRAIG ROBERT VANDER MAAS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE DR SE SUITE 305
GRAND RAPIDS MI
47546
US

IV. Provider business mailing address

61 COMMERCE AVE SW
GRAND RAPIDS MI
49503-4124
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-1377
  • Fax: 616-285-1006
Mailing address:
  • Phone: 616-940-0660
  • Fax: 616-940-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401003522
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301011634
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: