Basic Information
| Provider Information | |||||||||
| NPI: | 1477745875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERTULIP | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDERTULIP | ||||||||
| OtherFirstName: | VERONICA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA,BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3100 PREMIER DRIVE | ||||||||
| Address2: | SUITE 234 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750633602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103361524 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1401 UNIVERSAL CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | UNIVERSAL CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781483317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103361524 | ||||||||
| FaxNumber: | 2103460277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2007 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1345 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.