Healthcare Provider Details

I. General information

NPI: 1629224001
Provider Name (Legal Business Name): MELISSA LYNN VANDER KOOI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA LYNN DE GROFF NONE

II. Dates (important events)

Enumeration Date: 08/17/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2663 44TH ST SW
WYOMING MI
49519-4189
US

IV. Provider business mailing address

2663 44TH ST SW STE 106
WYOMING MI
49519-4189
US

V. Phone/Fax

Practice location:
  • Phone: 616-822-5518
  • Fax:
Mailing address:
  • Phone: 616-258-2066
  • Fax: 866-752-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401007890
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: