Basic Information
| Provider Information | |||||||||
| NPI: | 1508282120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERLOOVEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481985752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344310087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 N 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481045503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342223750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2014 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801113753 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1508282120 | 05 | MI | MEDICAID |