Provider Demographics
NPI:1669001665
Name:VANDERWAAL, MICHAEL JON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JON
Last Name:VANDERWAAL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2207
Mailing Address - Country:US
Mailing Address - Phone:816-200-2320
Mailing Address - Fax:
Practice Address - Street 1:4110 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2303
Practice Address - Country:US
Practice Address - Phone:816-200-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021597104100000X
MO20210386931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty