Provider Demographics
NPI:1710903240
Name:VANDALE, CARA J (OT)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:J
Last Name:VANDALE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:304-744-2300
Mailing Address - Fax:304-744-8195
Practice Address - Street 1:313 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1263
Practice Address - Country:US
Practice Address - Phone:304-744-2300
Practice Address - Fax:304-744-8195
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0159443000Medicaid
001720898OtherMOUNTAIN STATE BCBS
670001502OtherRR MEDICARE
000000217244OtherANTHEM BCBS
OH000000204383OtherOH MEDICAID UNISON
WVP00884476OtherWV RAIL ROAD MEDICARE
001720898OtherMOUNTAIN STATE BCBS