Provider Demographics
NPI:1225266950
Name:VANDERBILT, CAROLE L (MS)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:L
Last Name:VANDERBILT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3056 CASTRO VALLEY BLVD # 80
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5510
Mailing Address - Country:US
Mailing Address - Phone:510-325-5332
Mailing Address - Fax:
Practice Address - Street 1:21314 GARY DR APT 201
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-6129
Practice Address - Country:US
Practice Address - Phone:510-325-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAREGISTERED INTERN #4101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health