Basic Information
| Provider Information | |||||||||
| NPI: | 1073970604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBURG | ||||||||
| FirstName: | KARI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 VESTA RD | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195396502 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 VESTA RD | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195396502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | CG60628942 | WA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YP2500X | LPC.0017629 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.