Provider Demographics
NPI:1093104705
Name:VANDERHORST, ALYSE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:VANDERHORST
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 HORSESHOE DR SE
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-8638
Mailing Address - Country:US
Mailing Address - Phone:231-534-3404
Mailing Address - Fax:
Practice Address - Street 1:4450 HORSESHOE DR SE
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8638
Practice Address - Country:US
Practice Address - Phone:231-534-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401000392103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician