Provider Demographics
NPI:1205210499
Name:VANDENBERG, ERIKA
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:VANDENBERG
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 1:1530 FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 FREEDOM RD
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-1315
Practice Address - Country:US
Practice Address - Phone:920-850-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4159-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist