Healthcare Provider Details

I. General information

NPI: 1841480761
Provider Name (Legal Business Name): MICHAEL JACOBUS VAN GELDER M.S., M.N., PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9631 N NEVADA ST STE 209
SPOKANE WA
99218-1197
US

IV. Provider business mailing address

9631 N NEVADA ST STE 209
SPOKANE WA
99218-1197
US

V. Phone/Fax

Practice location:
  • Phone: 509-591-9007
  • Fax:
Mailing address:
  • Phone: 509-591-9007
  • Fax: 509-593-4676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201250114NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60319975
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00057879
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201043039RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: