Provider Demographics
NPI:1407187180
Name:VONDRACEK, DEBRA LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:VONDRACEK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1301 KS HWY 264
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-5353
Mailing Address - Country:US
Mailing Address - Phone:620-285-4711
Mailing Address - Fax:
Practice Address - Street 1:1301 KS HWY 264
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-5353
Practice Address - Country:US
Practice Address - Phone:620-285-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP 1433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSLP-1433OtherLICENSE NUMBER
KST-LP 1856OtherLICENSE NUMBER