Basic Information
| Provider Information | |||||||||
| NPI: | 1942753199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERWEELE | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 HEMLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490241158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695015017 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6130 LOVERS LN | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490023026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695015017 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2016 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801100053 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.