Provider Demographics
NPI:1629400981
Name:VANDENBUSSCHE, KRISTIN MADDOX (LCSW-A)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MADDOX
Last Name:VANDENBUSSCHE
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-752-0074
Practice Address - Street 1:2245 STANTONSBURG RD
Practice Address - Street 2:STE O
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2868
Practice Address - Country:US
Practice Address - Phone:252-752-0483
Practice Address - Fax:252-757-3172
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0082991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical