Provider Demographics
NPI:1346586435
Name:VANDIVER, ADAM SHAWN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:SHAWN
Last Name:VANDIVER
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 1:545 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3608
Mailing Address - Country:US
Mailing Address - Phone:619-579-0947
Mailing Address - Fax:
Practice Address - Street 1:545 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3608
Practice Address - Country:US
Practice Address - Phone:619-579-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW6051101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)