Provider Demographics
NPI:1447220819
Name:VANDERGOOT, MARY ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:VANDERGOOT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MONROE CTR NW
Mailing Address - Street 2:SUITE 8-D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2916
Mailing Address - Country:US
Mailing Address - Phone:616-957-3477
Mailing Address - Fax:
Practice Address - Street 1:60 MONROE CTR NW
Practice Address - Street 2:SUITE 8-D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2916
Practice Address - Country:US
Practice Address - Phone:616-957-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6201002122103T00000X
MI4101005656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D14542OtherBLUE CROSS BLUE SHIELD