Provider Demographics
NPI:1891514857
Name:VAN AST, KARIN MAYOGA (LLC)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:MAYOGA
Last Name:VAN AST
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6404
Mailing Address - Country:US
Mailing Address - Phone:616-217-9934
Mailing Address - Fax:
Practice Address - Street 1:5360 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6404
Practice Address - Country:US
Practice Address - Phone:616-217-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023933101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional