Individual
MRS. MARY VANDERWAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTAL, DOR
Contact information
Practice address
2320 E BELTLINE AVE SE, GRAND RAPIDS, MI 49546-5906
(616) 831-8643
Mailing address
9199 WHITNEYVILLE AVE SE, ALTO, MI 49302-9567
(616) 292-5760
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5202004267
MI
Other
Enumeration date
02/12/2019
Last updated
02/12/2019
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