Provider Demographics
NPI:1679682637
Name:VANDER WAAL, CHERYL ANN (MSW)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:ANN
Last Name:VANDER WAAL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 HEADLANDS CT
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1093
Mailing Address - Country:US
Mailing Address - Phone:415-465-2811
Mailing Address - Fax:415-331-2486
Practice Address - Street 1:254 HEADLANDS CT
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1093
Practice Address - Country:US
Practice Address - Phone:415-465-2811
Practice Address - Fax:415-331-2486
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS030931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
154736OtherMHN
CA4465740Medicaid
5114667OtherAETNA
CA4465740Medicaid