Provider Demographics
NPI:1316912702
Name:VANDERPOL, WILMAR G (EDD)
Entity type:Individual
Prefix:
First Name:WILMAR
Middle Name:G
Last Name:VANDERPOL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:WILMAR
Other - Middle Name:G
Other - Last Name:VANDERPOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:805 S CARMEL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2344
Mailing Address - Country:US
Mailing Address - Phone:231-775-6517
Mailing Address - Fax:231-775-6587
Practice Address - Street 1:805 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2344
Practice Address - Country:US
Practice Address - Phone:231-775-6517
Practice Address - Fax:231-775-6587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006587103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM27300002Medicare ID - Type Unspecified
MIWV006587Medicare UPIN