Provider Demographics
NPI:1386785087
Name:VANDUSEN, CAROL ANN (MS, LMHC)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:VANDUSEN
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12012 SOUTHSHORE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6203
Mailing Address - Country:US
Mailing Address - Phone:561-790-4721
Mailing Address - Fax:561-790-4788
Practice Address - Street 1:12012 SOUTHSHORE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6203
Practice Address - Country:US
Practice Address - Phone:561-790-4721
Practice Address - Fax:561-790-4788
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061735994OtherTAX ID NUMBER