Provider Demographics
NPI:1568858470
Name:VREDENBURGH, AMY (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VREDENBURGH
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 SW GEMINI DR
Mailing Address - Street 2:PMB 14034
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008
Mailing Address - Country:US
Mailing Address - Phone:612-876-6586
Mailing Address - Fax:
Practice Address - Street 1:905 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3186
Practice Address - Country:US
Practice Address - Phone:612-876-6586
Practice Address - Fax:218-585-1586
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2962101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNL232112102607OtherMINNESOTA LISCENCE