Provider Demographics
NPI:1760655062
Name:VANDERVEEN, TIMOTHY HUGH (MA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:HUGH
Last Name:VANDERVEEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 W US HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85273-3429
Mailing Address - Country:US
Mailing Address - Phone:253-208-1272
Mailing Address - Fax:
Practice Address - Street 1:1113 W US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:AZ
Practice Address - Zip Code:85273-3429
Practice Address - Country:US
Practice Address - Phone:253-208-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4003175103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool