Healthcare Provider Details

I. General information

NPI: 1356550644
Provider Name (Legal Business Name): MATTHEW VANDERHYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 NORTHLAND DR NE STE B
GRAND RAPIDS MI
49525-1073
US

IV. Provider business mailing address

8975 OTTOGAN ST
HOLLAND MI
49423-9036
US

V. Phone/Fax

Practice location:
  • Phone: 616-344-4785
  • Fax:
Mailing address:
  • Phone: 616-443-5471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801091508
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801091508
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: