Provider Demographics
NPI:1326291170
Name:VANDERKOLK, STACEY MICHELLE (BA CADC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MICHELLE
Last Name:VANDERKOLK
Suffix:
Gender:F
Credentials:BA CADC
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107
Mailing Address - Country:US
Mailing Address - Phone:815-391-1000
Mailing Address - Fax:815-391-5040
Practice Address - Street 1:54 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3837
Practice Address - Country:US
Practice Address - Phone:608-752-8716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL42254500Medicaid