Basic Information
| Provider Information | |||||||||
| NPI: | 1861583361 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VANDIVIER AND ASSOCIATES PSC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 903 BAXTER AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402042046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024587366 | ||||||||
| FaxNumber: | 5024587362 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 BAXTER AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402042046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024587366 | ||||||||
| FaxNumber: | 5024587362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDIVIER | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5024587366 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000000060157 | 01 | ANTHEM BCBS | OTHER |