Basic Information
Provider Information | |||||||||
NPI: | 1689964397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDYKE | ||||||||
FirstName: | KOURTNEE | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAURIA | ||||||||
OtherFirstName: | KOURTNEE | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1847 | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494431847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317281663 | ||||||||
FaxNumber: | 2317274571 | ||||||||
Practice Location | |||||||||
Address1: | 2006 HOLTON RD | ||||||||
Address2: |   | ||||||||
City: | NORTH MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494451505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2316723333 | ||||||||
FaxNumber: | 2316726526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2011 | ||||||||
LastUpdateDate: | 08/23/2019 | ||||||||
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 | 104100000X | 6801090826 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 1689964397 | 05 | MI |   | MEDICAID |