Provider Demographics
NPI:1104626589
Name:VANDERMEER, MIA JEAN (SUDPT)
Entity type:Individual
Prefix:MS
First Name:MIA
Middle Name:JEAN
Last Name:VANDERMEER
Suffix:
Gender:
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:898 MILL ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-2911
Mailing Address - Country:US
Mailing Address - Phone:971-204-5681
Mailing Address - Fax:
Practice Address - Street 1:2924 FALK RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-5604
Practice Address - Country:US
Practice Address - Phone:360-690-3069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61578056101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)