Provider Demographics
NPI:1174864979
Name:VANDERBILT, KENWANA MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENWANA
Middle Name:MICHELLE
Last Name:VANDERBILT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KENWANA
Other - Middle Name:MICHELLE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:MACON OUTPATIENT CLINIC- 5398 THOMASTON RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220
Mailing Address - Country:US
Mailing Address - Phone:478-476-8868
Mailing Address - Fax:478-476-8161
Practice Address - Street 1:MACON OUTPATIENT CLINIC- 5398 THOMASTON RD.
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220
Practice Address - Country:US
Practice Address - Phone:478-476-8868
Practice Address - Fax:478-476-8161
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003494103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical