Provider Demographics
NPI:1629224001
Name:VANDER KOOI, MELISSA LYNN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNN
Last Name:VANDER KOOI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:DE GROFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NONE
Mailing Address - Street 1:2663 44TH ST SW STE 106
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4189
Mailing Address - Country:US
Mailing Address - Phone:616-258-2066
Mailing Address - Fax:866-752-2359
Practice Address - Street 1:2663 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4189
Practice Address - Country:US
Practice Address - Phone:616-822-5518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007890101Y00000X
MI6301013908103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor