Individual
MRS. STACEY MICHELLE VANDERKOLK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BA CADC
Contact information
Practice address
54 S JACKSON ST, JANESVILLE, WI 53548-3837
(608) 752-8716
Mailing address
1601 UNIVERSITY DRIVE, ROCKFORD, IL 61107
(815) 391-1000
(815) 391-5040
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
22263
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42254500
—
IL
Enumeration date
10/24/2008
Last updated
07/22/2009
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