Provider Demographics
NPI:1376689695
Name:VANDENBERG, PAULINE W (LPC)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:W
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 APPLETON ROAD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952
Mailing Address - Country:US
Mailing Address - Phone:920-939-4226
Mailing Address - Fax:920-739-7639
Practice Address - Street 1:1810 APPLETON ROAD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952
Practice Address - Country:US
Practice Address - Phone:920-939-4226
Practice Address - Fax:920-739-7639
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3029125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43554100Medicaid