Provider Demographics
NPI:1598437089
Name:VONGEMMINGEN, BETH ELLEN (LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:VONGEMMINGEN
Suffix:
Gender:F
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:E
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 S FRONTAGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2481
Mailing Address - Country:US
Mailing Address - Phone:651-500-0905
Mailing Address - Fax:651-437-2616
Practice Address - Street 1:1320 S FRONTAGE RD STE 200
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2481
Practice Address - Country:US
Practice Address - Phone:651-500-0905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300876101YA0400X
MN00073101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)