Provider Demographics
NPI:1962567735
Name:VANDER WALL, KATHLEEN RUTH (AUD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RUTH
Last Name:VANDER WALL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 ELM ST
Mailing Address - Street 2:# 204
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4522
Mailing Address - Country:US
Mailing Address - Phone:775-329-7017
Mailing Address - Fax:
Practice Address - Street 1:343 ELM ST
Practice Address - Street 2:# 204
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4522
Practice Address - Country:US
Practice Address - Phone:775-329-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-044231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVR10050Medicare UPIN