Provider Demographics
NPI:1902549611
Name:VANDER GRIEND, SUSAN KIM
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KIM
Last Name:VANDER GRIEND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:KIM-VANDERGRIEND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1240 BATES ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 COLLEGE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5921
Practice Address - Country:US
Practice Address - Phone:616-466-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511073891041C0700X
MI68011156331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical