Basic Information
| Provider Information | |||||||||
| NPI: | 1366819815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANNIEULANDE | ||||||||
| FirstName: | KELLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15930 19 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864640175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 SYLVAN AVE STE 1110 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD CLIFFS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076323118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6468736600 | ||||||||
| FaxNumber: | 6468594440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2015 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-22-58779 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.