Provider Demographics
NPI:1639338981
Name:VANDERWALKER, BETH E (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:E
Last Name:VANDERWALKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1148
Mailing Address - Country:US
Mailing Address - Phone:517-782-6674
Mailing Address - Fax:
Practice Address - Street 1:432 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1148
Practice Address - Country:US
Practice Address - Phone:517-782-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010012401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical