Basic Information
| Provider Information | |||||||||
| NPI: | 1013019959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDER VELDEN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | MHR, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4261 CHESNEY GLEN DR | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370764431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155844161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 ADAMS LN STE 11 | ||||||||
| Address2: | |||||||||
| City: | MT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371228320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157731561 | ||||||||
| FaxNumber: | 6157731564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 0000000791 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.