Provider Demographics
NPI:1609424852
Name:VENDETTI, CASEY LYNN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:VENDETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12596 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-4429
Mailing Address - Country:US
Mailing Address - Phone:443-684-9070
Mailing Address - Fax:
Practice Address - Street 1:280 STAFFORD ROAD
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:MD
Practice Address - Zip Code:20610
Practice Address - Country:US
Practice Address - Phone:410-535-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCEP821053299OtherBCBS