Provider Demographics
NPI:1225486376
Name:VANDERVOLGEN, REBECCA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:VANDERVOLGEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST
Mailing Address - Street 2:STE. 204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3742
Mailing Address - Country:US
Mailing Address - Phone:858-514-0375
Mailing Address - Fax:858-514-0383
Practice Address - Street 1:3760 CONVOY ST
Practice Address - Street 2:STE. 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3742
Practice Address - Country:US
Practice Address - Phone:858-514-0375
Practice Address - Fax:858-514-0383
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist