Healthcare Provider Details

I. General information

NPI: 1760655062
Provider Name (Legal Business Name): TIMOTHY HUGH VANDERVEEN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 W US HIGHWAY 60
SUPERIOR AZ
85273-3429
US

IV. Provider business mailing address

1113 W US HIGHWAY 60
SUPERIOR AZ
85273-3429
US

V. Phone/Fax

Practice location:
  • Phone: 253-208-1272
  • Fax:
Mailing address:
  • Phone: 253-208-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4003175
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: