Provider Demographics
NPI:1255700449
Name:VANDERLELY, KRISTEN (MS, ITDS)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:VANDERLELY
Suffix:
Gender:F
Credentials:MS, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 SW 13TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4147
Mailing Address - Country:US
Mailing Address - Phone:954-815-4738
Mailing Address - Fax:
Practice Address - Street 1:1609 SW 13TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-4147
Practice Address - Country:US
Practice Address - Phone:954-815-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker