Provider Demographics
NPI:1366043408
Name:VAN DER WATH, AZELDRI (LCSW)
Entity Type:Individual
Prefix:
First Name:AZELDRI
Middle Name:
Last Name:VAN DER WATH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 W BIG BEAVER RD STE 780
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4745
Mailing Address - Country:US
Mailing Address - Phone:248-215-2716
Mailing Address - Fax:
Practice Address - Street 1:888 W BIG BEAVER RD STE 780
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4745
Practice Address - Country:US
Practice Address - Phone:248-215-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011067101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical