Provider Demographics
NPI:1760961585
Name:VANKLOMPENBERG, BRANDI N (MA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:N
Last Name:VANKLOMPENBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7561 NW 16TH ST APT 2208
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33313-5127
Mailing Address - Country:US
Mailing Address - Phone:616-848-4361
Mailing Address - Fax:
Practice Address - Street 1:570 CLINTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2334
Practice Address - Country:US
Practice Address - Phone:313-224-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016650103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist