Basic Information
| Provider Information | |||||||||
| NPI: | 1457881310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDEVYVER | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480821243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5868198221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22708 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480801823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864452210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801100549 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801108788 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.