Provider Demographics
NPI:1396351995
Name:VANDER WAL, AUDREY JOY-BAKER (MA, LPC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JOY-BAKER
Last Name:VANDER WAL
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3031
Mailing Address - Country:US
Mailing Address - Phone:719-310-4557
Mailing Address - Fax:
Practice Address - Street 1:2305 E PARIS AVE SE STE 203
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2426
Practice Address - Country:US
Practice Address - Phone:616-816-1758
Practice Address - Fax:616-333-7685
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223152101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional