Healthcare Provider Details

I. General information

NPI: 1982133880
Provider Name (Legal Business Name): KATHEREINE MARIE VANDERWEYST OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 BROADWAY ST STE 210
ALEXANDRIA MN
56308-2688
US

IV. Provider business mailing address

324 BROADWAY ST STE 210
ALEXANDRIA MN
56308-2688
US

V. Phone/Fax

Practice location:
  • Phone: 320-815-9065
  • Fax:
Mailing address:
  • Phone: 320-815-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1087053-1-HCBS
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2835
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: