Provider Demographics
NPI:1821554031
Name:VANDERWAL, MARY (COTAL, DOR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:VANDERWAL
Suffix:
Gender:F
Credentials:COTAL, DOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9199 WHITNEYVILLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9567
Mailing Address - Country:US
Mailing Address - Phone:616-292-5760
Mailing Address - Fax:
Practice Address - Street 1:2320 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5906
Practice Address - Country:US
Practice Address - Phone:616-831-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202004267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty