Healthcare Provider Details

I. General information

NPI: 1669803094
Provider Name (Legal Business Name): BRENDA SUE VANDENBERG C.O.T.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2786 56TH ST TENDERCARE WYOMING
WYOMING MI
49418
US

IV. Provider business mailing address

1875 108TH ST SW
BYRON CENTER MI
49315
US

V. Phone/Fax

Practice location:
  • Phone: 616-261-3960
  • Fax: 616-261-3925
Mailing address:
  • Phone: 616-308-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202006468
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: