Healthcare Provider Details

I. General information

NPI: 1205497088
Provider Name (Legal Business Name): SERINA J VANDERBUSH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

IV. Provider business mailing address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

V. Phone/Fax

Practice location:
  • Phone: 734-850-6903
  • Fax: 734-850-0520
Mailing address:
  • Phone: 734-850-6903
  • Fax: 734-850-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801104896
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: