Basic Information
| Provider Information | |||||||||
| NPI: | 1396990404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCAMPEN | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 HALLETT ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492023109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177689019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177877920 | ||||||||
| FaxNumber: | 5177872440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401010356 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.