Basic Information
| Provider Information | |||||||||
| NPI: | 1629400981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDENBUSSCHE | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | MADDOX | ||||||||
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| Credential: | LCSW-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 SAPPHIRE CT STE 110 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278349079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | 2527520074 | ||||||||
| Practice Location | |||||||||
| Address1: | 2245 STANTONSBURG RD | ||||||||
| Address2: | STE O | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527573172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2013 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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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 | 1041C0700X | P008299 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.