Provider Demographics
NPI:1811252737
Name:VANDENBERG, STACEY LYNN (MA, LPC, NCC, CAADC)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:MA, LPC, NCC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 DENVER DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2196
Mailing Address - Country:US
Mailing Address - Phone:231-343-2781
Mailing Address - Fax:
Practice Address - Street 1:2305 E PARIS AVE SE
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:231-343-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2015-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional