Provider Demographics
NPI:1265528996
Name:VANOOSTERHOUT, ROBERT J (MA,LLP,CSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:VANOOSTERHOUT
Suffix:
Gender:M
Credentials:MA,LLP,CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9249 WEST LAKE CITY ROAD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:
Practice Address - Street 1:9249 WEST LAKE CITY ROAD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629
Practice Address - Country:US
Practice Address - Phone:989-422-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002552103T00000X
MI68010169091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ03104Medicare UPIN
MIG27604080Medicare PIN
MIN81320001Medicare PIN