Provider Demographics
NPI:1831536051
Name:VREDEVELD, MALLORY (MA, LLPC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:VREDEVELD
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E WASHINGTON AVE
Mailing Address - Street 2:SUITE 284
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2393
Mailing Address - Country:US
Mailing Address - Phone:517-789-6444
Mailing Address - Fax:517-789-5049
Practice Address - Street 1:209 E WASHINGTON AVE
Practice Address - Street 2:SUITE 284
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2393
Practice Address - Country:US
Practice Address - Phone:517-789-6444
Practice Address - Fax:517-789-5049
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012772101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor