Provider Demographics
NPI:1912471863
Name:CATHERINE A VANDEWEGE LLC
Entity Type:Organization
Organization Name:CATHERINE A VANDEWEGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:HINTON VANDEWEGE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CAADC
Authorized Official - Phone:616-574-4098
Mailing Address - Street 1:2250 SYLVAN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5253
Mailing Address - Country:US
Mailing Address - Phone:616-574-4098
Mailing Address - Fax:313-202-8257
Practice Address - Street 1:800 MONROE AVE NW STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1448
Practice Address - Country:US
Practice Address - Phone:616-574-4098
Practice Address - Fax:313-202-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1225245517Medicaid