Provider Demographics
NPI:1457951659
Name:ZANDSTRA, MICHAEL LEO
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEO
Last Name:ZANDSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HALL ST SW STE 263
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4988
Mailing Address - Country:US
Mailing Address - Phone:616-719-0919
Mailing Address - Fax:
Practice Address - Street 1:401 HALL ST SW STE 263
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4988
Practice Address - Country:US
Practice Address - Phone:616-719-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011075611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical