Provider Demographics
NPI:1053903617
Name:VANERDEN, ALEXANDRIA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:VANERDEN
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 1:854 TECHNOLOGY WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5350
Mailing Address - Country:US
Mailing Address - Phone:847-816-7200
Mailing Address - Fax:
Practice Address - Street 1:854 TECHNOLOGY WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5350
Practice Address - Country:US
Practice Address - Phone:847-816-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty