Provider Demographics
NPI:1215002811
Name:DE WAARD, SUSAN (MA, LLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:DE WAARD
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:DE WAARD
Other - Last Name:BRUGGINK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:201 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4513
Mailing Address - Country:US
Mailing Address - Phone:616-459-4212
Mailing Address - Fax:616-774-9022
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-459-4212
Practice Address - Fax:616-774-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010025541041C0700X, 103T00000X, 103TB0200X, 103TC0700X
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16159Medicare ID - Type UnspecifiedMEDICADRE GROUP TOUCHSTON