MEDICARE: MS. STACEY M VANDERKLOK LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6801081440	MI
2	1041C0700X	Clinical Social Worker	6801081440	MI

General Provider Information

NPI Number	:	1578653986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACEY M VANDERKLOK LMSW

Provider Business Mailing Address
First Line	:	410 DAKOTA DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-6956
Country	:	US
Telephone Number	:	616-350-3968
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 3 MILE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-1685
Country	:	US
Telephone Number	:	616-207-3292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	04/24/2023

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