Provider Demographics
NPI:1790759587
Name:VANHAVERE, KATHLEEN R (MA, RD, CDE, CDN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:VANHAVERE
Suffix:
Gender:F
Credentials:MA, RD, CDE, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5036
Mailing Address - Country:US
Mailing Address - Phone:203-794-5637
Mailing Address - Fax:203-794-5642
Practice Address - Street 1:25 GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5036
Practice Address - Country:US
Practice Address - Phone:203-794-5637
Practice Address - Fax:203-794-5642
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003627133V00000X
CT000850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133884168OtherBEECH STREET
NY133884168OtherHORIZON OF NY
NY133884168OtherGHI PPO