Provider Demographics
NPI:1265469035
Name:VANDERKWAAK, VICKI LYNN (LISW)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:VANDERKWAAK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219
Mailing Address - Country:US
Mailing Address - Phone:641-628-9599
Mailing Address - Fax:641-621-1493
Practice Address - Street 1:6200 AURORA AVE
Practice Address - Street 2:STE 302W
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2800
Practice Address - Country:US
Practice Address - Phone:515-331-0303
Practice Address - Fax:515-331-9086
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0136879Medicaid
IA51220Medicare ID - Type Unspecified
IA0136879Medicaid