Provider Demographics
NPI:1295906915
Name:VANDER WAAL, MICHELLE G (PMHNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:G
Last Name:VANDER WAAL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 HIGHWAY 101 N
Mailing Address - Street 2:
Mailing Address - City:GEARHART
Mailing Address - State:OR
Mailing Address - Zip Code:97138-4321
Mailing Address - Country:US
Mailing Address - Phone:503-738-3832
Mailing Address - Fax:503-738-3466
Practice Address - Street 1:3619 HIGHWAY 101 N
Practice Address - Street 2:
Practice Address - City:GEARHART
Practice Address - State:OR
Practice Address - Zip Code:97138-4321
Practice Address - Country:US
Practice Address - Phone:503-738-3832
Practice Address - Fax:503-738-3466
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350142NP101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health