Provider Demographics
NPI:1043463938
Name:VANDEN HOOGEN, SHAUNA S (SAC)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:S
Last Name:VANDEN HOOGEN
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1115
Mailing Address - Country:US
Mailing Address - Phone:920-720-3700
Mailing Address - Fax:
Practice Address - Street 1:1095 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1115
Practice Address - Country:US
Practice Address - Phone:920-720-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15563101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)