Provider Demographics
NPI:1013147495
Name:BROCK-VANDERWALL, ARDEAN BETH (MDIV, MA)
Entity Type:Individual
Prefix:
First Name:ARDEAN
Middle Name:BETH
Last Name:BROCK-VANDERWALL
Suffix:
Gender:F
Credentials:MDIV, MA
Other - Prefix:
Other - First Name:ARDEAN
Other - Middle Name:BETH
Other - Last Name:BROCK-VANDERWALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MDIV, MA
Mailing Address - Street 1:3208 WOODBERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512
Mailing Address - Country:US
Mailing Address - Phone:616-893-6420
Mailing Address - Fax:616-891-9676
Practice Address - Street 1:2828 KRAFT AVE.
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512
Practice Address - Country:US
Practice Address - Phone:616-949-9550
Practice Address - Fax:616-949-9551
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional