Provider Demographics
NPI:1275088940
Name:VANDERVEST, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:VANDERVEST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 COCKSCROW LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3422
Mailing Address - Country:US
Mailing Address - Phone:714-227-9353
Mailing Address - Fax:
Practice Address - Street 1:1851 COCKSCROW LN
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3422
Practice Address - Country:US
Practice Address - Phone:714-227-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist