Provider Demographics
NPI:1578017471
Name:VANDERVORT, ERICA ANN (COTA)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:ANN
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:ERICA
Other - Middle Name:ANN
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:7222 W CERMAK RD
Mailing Address - Street 2:STE 500
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1422
Mailing Address - Country:US
Mailing Address - Phone:708-442-0023
Mailing Address - Fax:
Practice Address - Street 1:7222 W CERMAK RD
Practice Address - Street 2:STE 500
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1422
Practice Address - Country:US
Practice Address - Phone:708-442-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004570252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency