Provider Demographics
NPI:1609570241
Name:VANDERBURG, DAWN
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:VANDERBURG
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 1:1316 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1169
Mailing Address - Country:US
Mailing Address - Phone:607-664-4364
Mailing Address - Fax:
Practice Address - Street 1:1316 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1169
Practice Address - Country:US
Practice Address - Phone:607-664-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR086754-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical