Provider Demographics
NPI:1093337438
Name:VANDE VEGTE, LISA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VANDE VEGTE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24315 WALNUT ST APT 101
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2952
Mailing Address - Country:US
Mailing Address - Phone:619-971-4034
Mailing Address - Fax:
Practice Address - Street 1:28141 KELLY JOHNSON PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5003
Practice Address - Country:US
Practice Address - Phone:661-388-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0010036836OtherKAISER