Provider Demographics
NPI:1497774509
Name:VANDER MAAS, CRAIG ROBERT (PSYD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ROBERT
Last Name:VANDER MAAS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 305
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:47546
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003522101YP2500X
MI6301011634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
044021OtherVALUE OPTIONS
MI680D146850OtherBLUE CROSS BLUE SHIELD
MIM90290004Medicare PIN