Basic Information
| Provider Information | |||||||||
| NPI: | 1568885341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN VAERENBERGH | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 HOLLOWTREE DR | ||||||||
| Address2: | |||||||||
| City: | SEFFNER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335845826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136813242 | ||||||||
| FaxNumber: | 8136815835 | ||||||||
| Practice Location | |||||||||
| Address1: | 12512 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136446364 | ||||||||
| FaxNumber: | 8139723886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2014 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | FL | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.