Healthcare Provider Details

I. General information

NPI: 1174461636
Provider Name (Legal Business Name): EMILY MICHELLE VANDERBURG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

4374 SADDLEHORN DR
HUDSONVILLE MI
49426-8514
US

V. Phone/Fax

Practice location:
  • Phone: 269-673-1896
  • Fax:
Mailing address:
  • Phone: 269-447-7391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: