MEDICARE: CHRISTINE VANDERTOL MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	49416	CA
2	106H00000X	Marriage & Family Therapist	0717001469	VA

General Provider Information

NPI Number	:	1609173400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE VANDERTOL MFT

Provider Business Mailing Address
First Line	:	PO BOX 2902
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20177-7917
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 TEAROSE PL SW
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20175-2522
Country	:	US
Telephone Number	:	818-416-5979
Fax Number	:	818-584-8878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2011
Last Update Date	:	03/04/2020

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