Provider Demographics
NPI:1184334963
Name:VANDERSTELT, RENEE SANDRA (LGPAT, #ATG321)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:SANDRA
Last Name:VANDERSTELT
Suffix:
Gender:F
Credentials:LGPAT, #ATG321
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:SANDRA
Other - Last Name:VAN DER STELT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LGPAT, #ATG321
Mailing Address - Street 1:6219 WINDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9306
Mailing Address - Country:US
Mailing Address - Phone:443-909-0754
Mailing Address - Fax:
Practice Address - Street 1:1010 DULANEY VALLEY RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2702
Practice Address - Country:US
Practice Address - Phone:410-567-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATG321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional