Provider Demographics
NPI:1437240447
Name:VANDERLAAN, VICKIE L
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:L
Last Name:VANDERLAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:STE 109
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-728-5720
Mailing Address - Fax:231-728-5721
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:STE 109
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-728-5720
Practice Address - Fax:231-728-5721
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000084237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540F111730OtherBCBS SUPPLIER ID
MI904900723Medicaid
MI640F12603OtherBCBS AUDIO ID
MI640F12603OtherBCBS AUDIO ID