Provider Demographics
NPI:1790413029
Name:VAN ZANDT, VIVIAN MARIE (LSSP)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARIE
Last Name:VAN ZANDT
Suffix:
Gender:F
Credentials:LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 MERIDIAN DR APT 2408
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3248
Mailing Address - Country:US
Mailing Address - Phone:325-725-7352
Mailing Address - Fax:
Practice Address - Street 1:1505 MERIDIAN DR APT 2408
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-3248
Practice Address - Country:US
Practice Address - Phone:325-725-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71896103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty