Healthcare Provider Details

I. General information

NPI: 1790759587
Provider Name (Legal Business Name): KATHLEEN R VANHAVERE MA, RD, CDE, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 GERMANTOWN RD
DANBURY CT
06810-5036
US

IV. Provider business mailing address

25 GERMANTOWN RD
DANBURY CT
06810-5036
US

V. Phone/Fax

Practice location:
  • Phone: 203-794-5637
  • Fax: 203-794-5642
Mailing address:
  • Phone: 203-794-5637
  • Fax: 203-794-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number003627
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000850
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: