=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669875779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHY VARBONCOEUR CADC, SST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2014
-----------------------------------------------------
Last Update Date | 10/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1823 COMMERCE ST
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-728-2138
-----------------------------------------------------
Fax | 231-722-4771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18724 ELLENWOOD LN
-----------------------------------------------------
City | FRUITPORT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49415-9541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-740-9621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 6803058152
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2-00422
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------