Provider Demographics
NPI:1235788480
Name:VANDERVEEN, JOHN DAVIS (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVIS
Last Name:VANDERVEEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 E 2100 S APT 6312
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-6809
Mailing Address - Country:US
Mailing Address - Phone:248-736-1422
Mailing Address - Fax:
Practice Address - Street 1:615 S ARAPEEN DR STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1239
Practice Address - Country:US
Practice Address - Phone:581-801-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11176091-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical