Provider Demographics
NPI:1558864173
Name:VANDENKOOY, STEFAN (RBT)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:VANDENKOOY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 VIA MIRADA APT C
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1642
Mailing Address - Country:US
Mailing Address - Phone:360-421-1840
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4633
Practice Address - Country:US
Practice Address - Phone:360-421-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA601536272OtherBLUE CROSS / BLUE SHIELD
WAUDWW780110182OtherREGENCE