Provider Demographics
NPI:1447872197
Name:VANDERTUIN, MACKENNA LEE
Entity type:Individual
Prefix:
First Name:MACKENNA
Middle Name:LEE
Last Name:VANDERTUIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 11TH CIRCLE SE
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310
Mailing Address - Country:US
Mailing Address - Phone:219-742-7641
Mailing Address - Fax:
Practice Address - Street 1:400 11TH CIRCLE SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310
Practice Address - Country:US
Practice Address - Phone:219-742-7641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency