Provider Demographics
NPI:1649247875
Name:VANDEUSEN, KAREN M (PHD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:VANDEUSEN
Suffix:
Gender:F
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:PO BOX 120125
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0103
Mailing Address - Country:US
Mailing Address - Phone:616-942-8060
Mailing Address - Fax:616-942-6690
Practice Address - Street 1:4467 CASCADE RD SE SUITE 4481
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-942-8060
Practice Address - Fax:616-942-6690
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010798103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P10680Medicare ID - Type Unspecified