1114401080 NPI number — ROBIN GENE VANDEVENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114401080 NPI number — ROBIN GENE VANDEVENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDEVENTER
Provider First Name:
ROBIN
Provider Middle Name:
GENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114401080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 N TILLOTSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47304-3988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-288-1928
Provider Business Mailing Address Fax Number:
765-741-0335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 LAKE AVE STE 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-0932
Provider Business Practice Location Address Fax Number:
260-436-1185
Provider Enumeration Date:
09/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  88000671A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 88000671A . This is a "MENTAL HEALTH ASSOCIATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 14329568 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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