Healthcare Provider Details

I. General information

NPI: 1811252737
Provider Name (Legal Business Name): STACEY LYNN VANDENBERG MA, LPC, NCC, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 09/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

3531 DENVER DR
MUSKEGON MI
49445-2196
US

V. Phone/Fax

Practice location:
  • Phone: 231-343-2781
  • Fax:
Mailing address:
  • Phone: 231-343-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401006558
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: