Provider Demographics
NPI:1558569061
Name:VANDOREN, CAROLYN (PSY D)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:VANDOREN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 WILLETT AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2348
Mailing Address - Country:US
Mailing Address - Phone:815-677-4091
Mailing Address - Fax:
Practice Address - Street 1:631 WILLETT AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2348
Practice Address - Country:US
Practice Address - Phone:815-677-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist