Provider Demographics
NPI:1528430022
Name:VONDERSAAR, MARTIN KIPP
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:KIPP
Last Name:VONDERSAAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10159 MISSION GORGE RD STE C
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3857
Mailing Address - Country:US
Mailing Address - Phone:619-579-0947
Mailing Address - Fax:619-588-6282
Practice Address - Street 1:10159 MISSION GORGE RD STE C
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3857
Practice Address - Country:US
Practice Address - Phone:619-579-0947
Practice Address - Fax:619-588-6282
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)