Basic Information
| Provider Information | |||||||||
| NPI: | 1669803094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.O.T.A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1875 108TH ST SW | ||||||||
| Address2: | |||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163088736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2786 56TH ST | ||||||||
| Address2: | TENDERCARE WYOMING | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162613960 | ||||||||
| FaxNumber: | 6162613925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5202006468 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.