Provider Demographics
NPI:1003902495
Name:WACHTER, BRENDA ANN VETTE (LMSW ACSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:ANN VETTE
Last Name:WACHTER
Suffix:
Gender:F
Credentials:LMSW ACSW
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:ANN
Other - Last Name:VETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13462 RAVINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9179
Mailing Address - Country:US
Mailing Address - Phone:231-557-9799
Mailing Address - Fax:
Practice Address - Street 1:16175 ROBBINS RD STE 2
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-9403
Practice Address - Country:US
Practice Address - Phone:616-920-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010734601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003902495Medicaid