Provider Demographics
NPI:1518387851
Name:VANWYNGARDEN, SUSAN RENEE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:VANWYNGARDEN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 W 15TH ST STE 208-9
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3370
Mailing Address - Country:US
Mailing Address - Phone:616-594-7135
Mailing Address - Fax:
Practice Address - Street 1:96 W 15TH ST STE 208-9
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3370
Practice Address - Country:US
Practice Address - Phone:616-594-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401 010773101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional