Provider Demographics
NPI:1215087762
Name:VANDERKLOK, REGINA JO (BC-HIS)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:JO
Last Name:VANDERKLOK
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4598 PLAINFIELD AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1645
Mailing Address - Country:US
Mailing Address - Phone:616-364-0090
Mailing Address - Fax:616-364-7441
Practice Address - Street 1:4598 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1645
Practice Address - Country:US
Practice Address - Phone:616-364-0090
Practice Address - Fax:616-364-7441
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501002836237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4836981Medicaid
MI540D10522OtherBCBS