Provider Demographics
NPI:1912556119
Name:VANDERWEIDE, KATHRYN (LMSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:VANDERWEIDE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:77 MONROE CENTER ST NW STE 600
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2911
Mailing Address - Country:US
Mailing Address - Phone:616-287-3770
Mailing Address - Fax:269-408-1692
Practice Address - Street 1:77 MONROE CENTER ST NW STE 600
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2911
Practice Address - Country:US
Practice Address - Phone:616-287-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011056621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical