Provider Demographics
NPI:1104128362
Name:VANDENBERG, KATHRYN DENISE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:DENISE
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-2000
Mailing Address - Country:US
Mailing Address - Phone:530-748-9395
Mailing Address - Fax:
Practice Address - Street 1:3641 VISTA VIEW CIR
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:UT
Practice Address - Zip Code:84765-5655
Practice Address - Country:US
Practice Address - Phone:435-767-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-21
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13419436-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst