Provider Demographics
NPI:1821542218
Name:VANDER KODDE, DONNA KAY (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:KAY
Last Name:VANDER KODDE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MISS
Other - First Name:DONNA
Other - Middle Name:KAY
Other - Last Name:KNOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5242 PLAINFIELD AVE NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-236-3281
Mailing Address - Fax:616-734-6205
Practice Address - Street 1:5242 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-236-3281
Practice Address - Fax:616-734-6205
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVS0079950Medicaid