Provider Demographics
NPI:1508835141
Name:GUDVANGEN, DENISE ROSE (LP)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:ROSE
Last Name:GUDVANGEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:JADEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:603 BRUCE ST
Mailing Address - Street 2:PO BOX 603
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-0603
Mailing Address - Country:US
Mailing Address - Phone:218-281-3940
Mailing Address - Fax:218-281-6261
Practice Address - Street 1:603 BRUCE ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716
Practice Address - Country:US
Practice Address - Phone:218-281-3940
Practice Address - Fax:218-281-6261
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP28754OtherHEALTH PARTNERS
MN41B43JAOtherBCBS OF MN
MN123671OtherUCARE MINNESOTA