Provider Demographics
NPI:1750393773
Name:VANDEWEGE, COURTNEY ANN (ATC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANN
Last Name:VANDEWEGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1245
Mailing Address - Country:US
Mailing Address - Phone:616-322-3145
Mailing Address - Fax:
Practice Address - Street 1:2211 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3026
Practice Address - Country:US
Practice Address - Phone:616-322-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer