Provider Demographics
NPI:1568622983
Name:VAN DE WALKER, BERND STEPHEN (MMOT PT)
Entity Type:Individual
Prefix:
First Name:BERND
Middle Name:STEPHEN
Last Name:VAN DE WALKER
Suffix:
Gender:M
Credentials:MMOT PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 MONROE AVE NW STE 150
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1055
Mailing Address - Country:US
Mailing Address - Phone:616-459-6331
Mailing Address - Fax:
Practice Address - Street 1:383 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9602
Practice Address - Country:US
Practice Address - Phone:616-494-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINAOtherWORKERS COMPENSATION PATIENTS ONLY.AT THIS TIME.