Provider Demographics
NPI:1215102132
Name:VANDERVORT, CHRISTA J (SP)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:J
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 UINTA DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5060
Mailing Address - Country:US
Mailing Address - Phone:307-872-4500
Mailing Address - Fax:307-872-4595
Practice Address - Street 1:1400 UINTA DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5060
Practice Address - Country:US
Practice Address - Phone:307-872-4500
Practice Address - Fax:307-872-4595
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY080042349OtherRAILROAD MEDICARE PIN