Basic Information
| Provider Information | |||||||||
| NPI: | 1780882704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDORN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707656106 | ||||||||
| FaxNumber: | 2707690559 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707656106 | ||||||||
| FaxNumber: | 2707690559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | A1904 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.