Provider Demographics
NPI:1336354935
Name:VARGO, MICHAEL C (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:VARGO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 OTTAWA AVE NW
Mailing Address - Street 2:SUITE 300C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2701
Mailing Address - Country:US
Mailing Address - Phone:616-458-0692
Mailing Address - Fax:616-458-8129
Practice Address - Street 1:161 OTTAWA AVE NW
Practice Address - Street 2:SUITE 300C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2701
Practice Address - Country:US
Practice Address - Phone:616-458-0692
Practice Address - Fax:616-458-8129
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013182103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist