Provider Demographics
NPI:1962627620
Name:VANDENBERG, STEVEN PAUL (EDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:PAUL
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 E DETROIT PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-4168
Mailing Address - Country:US
Mailing Address - Phone:480-472-4420
Mailing Address - Fax:480-472-4597
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3307
Practice Address - Country:US
Practice Address - Phone:480-472-4420
Practice Address - Fax:480-472-4597
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ141112Medicaid