Provider Demographics
NPI:1760587323
Name:VANDERRYN, JUDITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:VANDERRYN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:VT
Mailing Address - Zip Code:05491-0125
Mailing Address - Country:US
Mailing Address - Phone:802-651-8999
Mailing Address - Fax:802-651-8997
Practice Address - Street 1:595 DORSET ST STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6240
Practice Address - Country:US
Practice Address - Phone:802-651-8999
Practice Address - Fax:802-651-8997
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0134642103TC0700X
CO2051103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO335446Medicare UPIN