Provider Demographics
NPI:1043460165
Name:VANIDERSTINE, PIETER CAMERON (MA)
Entity type:Individual
Prefix:MR
First Name:PIETER
Middle Name:CAMERON
Last Name:VANIDERSTINE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N ELM ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2878
Mailing Address - Country:US
Mailing Address - Phone:336-334-5601
Mailing Address - Fax:336-334-5657
Practice Address - Street 1:122 N ELM ST
Practice Address - Street 2:SUITE 400
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2878
Practice Address - Country:US
Practice Address - Phone:336-334-5601
Practice Address - Fax:336-334-5657
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1004103T00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3403407Medicaid