Provider Demographics
NPI:1013019959
Name:VANDER VELDEN, STEPHANIE MICHELLE (MHR, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:VANDER VELDEN
Suffix:
Gender:F
Credentials:MHR, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 CHESNEY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-4431
Mailing Address - Country:US
Mailing Address - Phone:615-584-4161
Mailing Address - Fax:
Practice Address - Street 1:151 ADAMS LN STE 11
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8320
Practice Address - Country:US
Practice Address - Phone:615-773-1561
Practice Address - Fax:615-773-1564
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000007912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer