Provider Demographics
NPI:1902007495
Name:VANDIVIER, DANNY K (PHD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:K
Last Name:VANDIVIER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2046
Mailing Address - Country:US
Mailing Address - Phone:502-458-7366
Mailing Address - Fax:502-458-7362
Practice Address - Street 1:903 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2046
Practice Address - Country:US
Practice Address - Phone:502-458-7366
Practice Address - Fax:502-458-7362
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0528103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000050056OtherANTHEM BCBS
000000050056OtherANTHEM BCBS