Basic Information
| Provider Information | |||||||||
| NPI: | 1912380593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBRONKHORST | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163363909 | ||||||||
| FaxNumber: | 6163368830 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163363909 | ||||||||
| FaxNumber: | 6163368830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2015 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301108468 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 293558 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 4301507541 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.