Provider Demographics
NPI:1225712433
Name:VANDERKLIPP, GRANT MICHAEL
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL
Last Name:VANDERKLIPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1377
Mailing Address - Country:US
Mailing Address - Phone:616-430-5424
Mailing Address - Fax:
Practice Address - Street 1:2104 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8355
Practice Address - Country:US
Practice Address - Phone:817-442-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician