Provider Demographics
NPI:1215395645
Name:VANDERHAM, MICHELLE (LISW-S, LICDC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:VANDERHAM
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6942 TYLERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6942 TYLERSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-7616
Practice Address - Country:US
Practice Address - Phone:513-795-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131132101YA0400X
OHI.15004831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)