MEDICARE: VANDIVIER AND ASSOCIATES PSC

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	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000060157	OTHER		ANTHEM BCBS

General Provider Information

NPI Number	:	1861583361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANDIVIER AND ASSOCIATES PSC

Provider Business Mailing Address
First Line	:	903 BAXTER AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2046
Country	:	US
Telephone Number	:	502-458-7366
Fax Number	:	502-458-7362

Provider Business Practice Location Address
First Line	:	903 BAXTER AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2046
Country	:	US
Telephone Number	:	502-458-7366
Fax Number	:	502-458-7362

Authorized Official
Title or Position	:	OWNER
Name	:	DAN K. VANDIVIER
Credential	:	PHD
Telephone Number	:	502-458-7366

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	08/22/2020

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