Provider Demographics
NPI:1174839336
Name:VANDERMAUSE, PATRICIA L (LPC ,CSAC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:VANDERMAUSE
Suffix:
Gender:F
Credentials:LPC ,CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2241
Mailing Address - Country:US
Mailing Address - Phone:920-433-3630
Mailing Address - Fax:
Practice Address - Street 1:301 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2241
Practice Address - Country:US
Practice Address - Phone:920-433-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4431-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicaid