Provider Demographics
NPI:1447237565
Name:VANDERBECK, D JOHN (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:JOHN
Last Name:VANDERBECK
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1034
Mailing Address - Country:US
Mailing Address - Phone:812-886-6800
Mailing Address - Fax:812-886-6809
Practice Address - Street 1:515 BAYOU ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1034
Practice Address - Country:US
Practice Address - Phone:812-886-6800
Practice Address - Fax:812-886-6809
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010229A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000188719OtherANTHEM BLUE CROSS
IN200018450Medicaid
IN200018450Medicaid