Provider Demographics
NPI:1174568422
Name:VANDRIE, MARY LYNN (MA,CCC-A)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:VANDRIE
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:810-177-1385
Mailing Address - Fax:810-733-7893
Practice Address - Street 1:705 W. LAKE LANSING ROAD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-337-2411
Practice Address - Fax:517-337-6033
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000092231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174568422Medicaid
MI1174568422Medicaid