Provider Demographics
NPI:1013154517
Name:VANDEWYNGEARDE, KATHERINE (LMSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:VANDEWYNGEARDE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 E 13 MILE RD
Mailing Address - Street 2:STE. 200
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3093
Mailing Address - Country:US
Mailing Address - Phone:586-573-1840
Mailing Address - Fax:586-573-2121
Practice Address - Street 1:12200 E 13 MILE RD
Practice Address - Street 2:STE. 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3093
Practice Address - Country:US
Practice Address - Phone:586-573-1810
Practice Address - Fax:586-573-2121
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68010912611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker