Basic Information
| Provider Information | |||||||||
| NPI: | 1790759587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANHAVERE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MA, RD, CDE, CDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068105036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037945637 | ||||||||
| FaxNumber: | 2037945642 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068105036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037945637 | ||||||||
| FaxNumber: | 2037945642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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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 | 133V00000X | 003627 | NY | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 000850 | CT | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 133884168 | 01 | NY | BEECH STREET | OTHER | 133884168 | 01 | NY | HORIZON OF NY | OTHER | 133884168 | 01 | NY | GHI PPO | OTHER |