Provider Demographics
NPI:1063922433
Name:VANDUSSEN, NICOLE MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:VANDUSSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15575 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-9615
Mailing Address - Country:US
Mailing Address - Phone:616-970-5858
Mailing Address - Fax:
Practice Address - Street 1:15575 40TH AVE
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-9615
Practice Address - Country:US
Practice Address - Phone:616-970-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801101765104100000X
MI68011112691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker