Provider Demographics
NPI:1548791619
Name:VANDERVORT, KATIE (LMFT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E ALOSTA AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-3102
Mailing Address - Country:US
Mailing Address - Phone:805-453-1660
Mailing Address - Fax:
Practice Address - Street 1:777 E ALOSTA AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-3102
Practice Address - Country:US
Practice Address - Phone:805-453-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT100371106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist